1952812331 NPI number — LARRY J. BONDERUD, OD

Table of content: (NPI 1952812331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952812331 NPI number — LARRY J. BONDERUD, OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY J. BONDERUD, OD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1952812331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
865 OILFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59474-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-434-5196
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 4TH AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONRAD
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59425-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-271-5517
Provider Business Practice Location Address Fax Number:
406-271-5518
Provider Enumeration Date:
10/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BONDERUD
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-434-5196

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  393 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00481389 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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