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General NPI Number Information
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NPI Number | 1386657906
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Entity Type | Individual
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Provider Name | EDITH BONGE RD/LD
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Gender | Female
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4300 WEST 7TH ST 11HC/LR
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City | LITTLE ROCK
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State | AR
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Zip | 72205
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Country | US
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Telephone | 501-257-5084
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Fax |
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Provider Business Mailing Address
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Address Line | 136 LIMOGES CT
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City | MAUMELLE
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State | AR
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Zip | 72113-6765
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Country | US
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Telephone | 501-851-0238
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 029
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License Number State | AR
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