Healthcare Provider Details

I. General information

NPI: 1245624923
Provider Name (Legal Business Name): BOB POND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 10TH AVE NW APT 108
MINOT ND
58703-2200
US

IV. Provider business mailing address

816 10TH AVE NW APT 108
MINOT ND
58703-2200
US

V. Phone/Fax

Practice location:
  • Phone: 701-720-2018
  • Fax:
Mailing address:
  • Phone: 701-720-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: