Healthcare Provider Details

I. General information

NPI: 1508177635
Provider Name (Legal Business Name): TAD S. BERGEN AUD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 N UNIVERSITY AVE
FARMINGTON UT
84025-2990
US

IV. Provider business mailing address

165 N UNIVERSITY AVE
FARMINGTON UT
84025-2990
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-6669
  • Fax:
Mailing address:
  • Phone: 385-300-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: