Healthcare Provider Details

I. General information

NPI: 1619119831
Provider Name (Legal Business Name): MATTHEW ELLIS BONANDER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 HERDSMAN DR
KRUM TX
76249-1556
US

IV. Provider business mailing address

4118 HERDSMAN DR
KRUM TX
76249-1556
US

V. Phone/Fax

Practice location:
  • Phone: 940-535-8105
  • Fax: 940-241-4204
Mailing address:
  • Phone: 940-535-8105
  • Fax: 940-241-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number35580
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1254357
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: