Healthcare Provider Details

I. General information

NPI: 1124293931
Provider Name (Legal Business Name): JOHN BONTRAGER II D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N MILL ST SUITE A
SAINT LOUIS MI
48880-1522
US

IV. Provider business mailing address

124 N MILL ST SUITE A
SAINT LOUIS MI
48880-1521
US

V. Phone/Fax

Practice location:
  • Phone: 989-681-6693
  • Fax: 989-681-6693
Mailing address:
  • Phone: 989-681-6693
  • Fax: 989-681-6693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2301004464
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: