Healthcare Provider Details

I. General information

NPI: 1114274503
Provider Name (Legal Business Name): DEREK BOND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 BUTLER ST
MACON MO
63552-1629
US

IV. Provider business mailing address

26604 STATE HWY T
EXCELLO MO
65247-2162
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-6244
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2001018647
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: