Provider Demographics
NPI:1386760957
Name:BERTAGNOLLI, MARY MARGARET (LAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:BERTAGNOLLI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 W BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2641
Mailing Address - Country:US
Mailing Address - Phone:406-585-7660
Mailing Address - Fax:406-586-2329
Practice Address - Street 1:2629 W BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2641
Practice Address - Country:US
Practice Address - Phone:406-585-7660
Practice Address - Fax:406-586-2329
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT87171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist