Healthcare Provider Details

I. General information

NPI: 1700824489
Provider Name (Legal Business Name): CHERYL BONGIOVANNI PHD, RVT, CWS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S J ST
LAKEVIEW OR
97630-1623
US

IV. Provider business mailing address

PO BOX 108
LAKEVIEW OR
97630-0105
US

V. Phone/Fax

Practice location:
  • Phone: 541-517-5169
  • Fax: 541-947-3339
Mailing address:
  • Phone: 541-517-5169
  • Fax: 541-947-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCERTIFIED WOUND SPEC
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: