Provider Demographics
NPI:1962761866
Name:BERGEVIN, GEORGE HOWARD (DC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:HOWARD
Last Name:BERGEVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:ST.JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559
Mailing Address - Country:US
Mailing Address - Phone:573-201-5956
Mailing Address - Fax:
Practice Address - Street 1:405 US HWY 50
Practice Address - Street 2:STE. 200
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084
Practice Address - Country:US
Practice Address - Phone:636-583-2192
Practice Address - Fax:636-583-7707
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO5559111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor