Healthcare Provider Details

I. General information

NPI: 1730011800
Provider Name (Legal Business Name): MATTHEW DOUGLAS BERGMAN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 EDGAR AVE STE C
RONCEVERTE WV
24970-1564
US

IV. Provider business mailing address

543 EDGAR AVE STE C
RONCEVERTE WV
24970-1564
US

V. Phone/Fax

Practice location:
  • Phone: 646-923-1218
  • Fax:
Mailing address:
  • Phone: 646-923-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number96234
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: