1881149433 NPI number — MR. CLARENCE LEONARD BONANDER JR.

Table of content: MR. CLARENCE LEONARD BONANDER JR. (NPI 1881149433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881149433 NPI number — MR. CLARENCE LEONARD BONANDER JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONANDER
Provider First Name:
CLARENCE
Provider Middle Name:
LEONARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881149433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-379-1704
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 MAIN ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55008-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-325-0300
Provider Business Practice Location Address Fax Number:
763-325-0301
Provider Enumeration Date:
08/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: GL0087 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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