Provider Demographics
NPI:1245618420
Name:BUNGE, MIRANDA (DC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BUNGE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8678 RAMSEY LN
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3862
Mailing Address - Country:US
Mailing Address - Phone:618-318-1351
Mailing Address - Fax:
Practice Address - Street 1:3407 FERN VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-3529
Practice Address - Country:US
Practice Address - Phone:502-961-9355
Practice Address - Fax:502-961-9357
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1234111N00000X
KY5471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor