Provider Demographics
NPI:1962945238
Name:BERGEN, CHANI
Entity type:Individual
Prefix:
First Name:CHANI
Middle Name:
Last Name:BERGEN
Suffix:
Gender:F
Credentials:
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 736
Mailing Address - Street 2:
Mailing Address - City:TOM BEAN
Mailing Address - State:TX
Mailing Address - Zip Code:75489
Mailing Address - Country:US
Mailing Address - Phone:940-783-3311
Mailing Address - Fax:
Practice Address - Street 1:505 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090
Practice Address - Country:US
Practice Address - Phone:940-783-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide