Healthcare Provider Details

I. General information

NPI: 1497246722
Provider Name (Legal Business Name): LARRY J. BONDERUD, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 OILFIELD AVE STE 1
SHELBY MT
59474-2702
US

IV. Provider business mailing address

865 OILFIELD AVE STE 1
SHELBY MT
59474-2702
US

V. Phone/Fax

Practice location:
  • Phone: 406-434-5196
  • Fax: 406-434-5197
Mailing address:
  • Phone: 406-434-5196
  • Fax: 406-434-5197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number393
License Number StateMT

VIII. Authorized Official

Name: LEANN APPLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-434-5196