Healthcare Provider Details

I. General information

NPI: 1972005361
Provider Name (Legal Business Name): JAKE BUNDY MOTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 MEMORIAL DR STE B
POCATELLO ID
83201-4073
US

IV. Provider business mailing address

5082 BRYLEE WAY
IONA ID
83427-4908
US

V. Phone/Fax

Practice location:
  • Phone: 208-235-4263
  • Fax:
Mailing address:
  • Phone: 435-669-2438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-1457
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: