Healthcare Provider Details

I. General information

NPI: 1912140773
Provider Name (Legal Business Name): BONNIE BEND MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3938 JOHN F KENNEDY PKWY SUITE F-11
FORT COLLINS CO
80525-3086
US

IV. Provider business mailing address

2318 TANGLEWOOD DR
FORT COLLINS CO
80525-1953
US

V. Phone/Fax

Practice location:
  • Phone: 970-204-0516
  • Fax: 970-204-6812
Mailing address:
  • Phone: 970-482-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: