Basic Information
| Provider Information | |||||||||
| NPI: | 1255738118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNDY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | LAVAN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4949 S 3535 W | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357577546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 267 N SPRING CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843329775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357929400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2014 | ||||||||
| LastUpdateDate: | 06/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.