Provider Demographics
NPI:1003212465
Name:LUNDBOHM, JACK (DC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LUNDBOHM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 6TH ST W UNIT B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3602
Mailing Address - Country:US
Mailing Address - Phone:406-897-5505
Mailing Address - Fax:406-862-9750
Practice Address - Street 1:39 6TH ST W UNIT B
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3602
Practice Address - Country:US
Practice Address - Phone:406-897-5505
Practice Address - Fax:406-862-9750
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3427111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor