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General NPI Number Information
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NPI Number | 1427174549
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Entity Type | Organization
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Legal Business Name | JENNETTE BERGSTEDT MD LLC
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 4150 NELSON RD STE E1
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4133
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Country | US
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Telephone | 337-474-2933
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Fax | 337-474-5283
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Provider Business Mailing Address
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Address Line | 4150 NELSON RD STE E1
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4133
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Country | US
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Telephone | 337-474-2933
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Fax | 337-474-5283
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNETTE SEPULVADO BERGSTEDT
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Credential | MD
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Telephone | 337-474-2933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | MD.021307
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License Number State | LA
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