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General NPI Number Information
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NPI Number | 1538351184
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Entity Type | Organization
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Legal Business Name | REUBEN BONTRAGER
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | 4439 JACKSON ST STE B
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City | MARIANNA
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State | FL
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Zip | 32448-4660
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Country | US
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Telephone | 850-482-2264
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Fax | 850-482-5270
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Provider Business Mailing Address
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Address Line | 4439 JACKSON ST STE B
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City | MARIANNA
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State | FL
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Zip | 32448-4660
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Country | US
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Telephone | 850-482-2264
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Fax | 850-482-5270
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MRS. CAROL SUTTON
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Credential | MD.
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Telephone | 850-482-2264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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