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NPI Code Detail

MEDICARE: BONNIE L. GUNCKEL RD LD

MEDICARE: BONNIE L. GUNCKEL RD LD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian37000176AIN
2133V00000XRegistered Dietitian2001OH

General Provider Information

NPI Number : 1053353458
Entity Type Code : Individual
Provider Name (Legal Business Name) : BONNIE L. GUNCKEL RD LD
Provider Business Mailing Address
First Line : 4210 FLAGSTAFF CV
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-4417
Country : US
Telephone Number : 260-489-9009
Fax Number : 260-489-5057
Provider Business Practice Location Address
First Line : 4210 FLAGSTAFF CV
Second Line :
City : FORT WAYNE
State : IN
Zip : 46815-4417
Country : US
Telephone Number : 260-489-9009
Fax Number : 260-489-5057
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/11/2006
Last Update Date : 12/17/2008

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