Healthcare Provider Details

I. General information

NPI: 1548441652
Provider Name (Legal Business Name): LAURA JEAN BODE RT(T),CMD,B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. LAURA JEAN FORTMAN

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARK VIEW PLACE
ST LOUIS MO
63110
US

IV. Provider business mailing address

3610 FOSSIL CREEK LN
WATERLOO IL
62298-4650
US

V. Phone/Fax

Practice location:
  • Phone: 618-210-1179
  • Fax:
Mailing address:
  • Phone: 618-210-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2471R0002X
TaxonomyRadiation Therapy Radiologic Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: