Healthcare Provider Details

I. General information

NPI: 1174984157
Provider Name (Legal Business Name): RACHEAL BUNDOR CEO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 JOHNSON RD
UPPER CHICHESTER PA
19061-3523
US

IV. Provider business mailing address

2604 JOHNSON RD
UPPER CHICHESTER PA
19061-3523
US

V. Phone/Fax

Practice location:
  • Phone: 267-408-2202
  • Fax: 484-229-1188
Mailing address:
  • Phone: 267-408-2202
  • Fax: 484-229-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License NumberCER-00091663
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: