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General NPI Number Information
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NPI Number | 1831910884
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Entity Type | Individual
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Provider Name | OMIE BERGQUIST R15730824
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Gender | Female
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Dates
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Enumeration Date | 10/22/2024
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Last Update Date | 10/22/2024
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Provider Practice Location Address
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Address Line | 69730 HIGHWAY 111 STE 109
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-2873
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Country | US
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Telephone | 760-322-1777
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Fax |
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Provider Business Mailing Address
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Address Line | 27 LAKEVIEW CIR
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City | CATHEDRAL CITY
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State | CA
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Zip | 92234-6056
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Country | US
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Telephone | 760-668-9399
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | R1573930824
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License Number State | CA
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