Provider Demographics
NPI:1265522965
Name:WATERFORD OUTPATIENT REHABILITATION CLINIC
Entity type:Organization
Organization Name:WATERFORD OUTPATIENT REHABILITATION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERGIN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, NHA
Authorized Official - Phone:360-854-2866
Mailing Address - Street 1:2911 SE VILLAGE LOOP
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8103
Mailing Address - Country:US
Mailing Address - Phone:360-433-6346
Mailing Address - Fax:360-891-4532
Practice Address - Street 1:2911 SE VILLAGE LOOP
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8103
Practice Address - Country:US
Practice Address - Phone:360-433-6346
Practice Address - Fax:360-891-4532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00007335225100000X
WA00007567225100000X
WA225200000X
WA00002309225X00000X
WA00002848225X00000X
WA00003218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty