Healthcare Provider Details

I. General information

NPI: 1043732993
Provider Name (Legal Business Name): CODY LUCAS BONTE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W UNIVERSITY AVE
MITCHELL SD
57301-4358
US

IV. Provider business mailing address

212 W ELM AVE
MITCHELL SD
57301-3311
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-2600
  • Fax:
Mailing address:
  • Phone: 605-321-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2000029735
License Number StateSD

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: