Basic Information
| Provider Information | |||||||||
| NPI: | 1730646779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELA CRUZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | BERGESCH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BERGESCH | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2340 CAROL VIEW DR APT E109 | ||||||||
| Address2: | |||||||||
| City: | CARDIFF BY THE SEA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920072039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107401003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3633 VISTA WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920564568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607297298 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 296285 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.