Healthcare Provider Details

I. General information

NPI: 1154074201
Provider Name (Legal Business Name): MATT BONANDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
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:
Mailing address:
  • Phone: 940-535-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW ELLIS BONANDER
Title or Position: PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 940-535-8105