=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619306032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUNGE CHIROPRACTIC HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2013
-----------------------------------------------------
Last Update Date | 03/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 PERSIMMONS ST STE 603
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-880-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 PERSIMMONS ST STE 603
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-880-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC L BUNGE SR.
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 814-880-1741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 3865
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------