Healthcare Provider Details

I. General information

NPI: 1083404966
Provider Name (Legal Business Name): ONE BREAD ONE BODY MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 CENTRAL AVE N STE 1
FARIBAULT MN
55021-4322
US

IV. Provider business mailing address

513 CENTRAL AVE N STE 1
FARIBAULT MN
55021-4322
US

V. Phone/Fax

Practice location:
  • Phone: 507-301-7602
  • Fax: 507-301-7602
Mailing address:
  • Phone: 507-301-7602
  • Fax: 507-301-7602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WENDY BONGERS
Title or Position: PRACTICE OWNER
Credential: MD
Phone: 507-301-7602