MEDICARE: DELANEY BERGEN ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	AT-704	ID

General Provider Information

NPI Number	:	1790399517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DELANEY BERGEN ATC, LAT

Provider Business Mailing Address
First Line	:	1727 SKYLANE DR
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-8701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	738 N COLLEGE RD STE C
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3387
Country	:	US
Telephone Number	:	208-316-5454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2020
Last Update Date	:	08/31/2020

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