Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2301004464 | MI |
NPI | 1124293931 |
---|---|
Provider Name | Dr. John Bontrager II |
First Address | Saint Louis, MI 48880-1521 |
Second Address | Saint Louis, MI 48880-1522 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/04/2008 |
Last Update Date | 17/01/2017 |