Healthcare Provider Details

I. General information

NPI: 1114736899
Provider Name (Legal Business Name): BOUNTIFUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JEFFERSON WAY STE 102
KETCHIKAN AK
99901-5953
US

IV. Provider business mailing address

25 JEFFERSON WAY STE 102
KETCHIKAN AK
99901-5953
US

V. Phone/Fax

Practice location:
  • Phone: 201-259-0289
  • Fax: 973-215-2052
Mailing address:
  • Phone: 201-259-0289
  • Fax: 973-215-2052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN ARTHUR HALL
Title or Position: OWNER
Credential: MD
Phone: 201-259-0289