Provider Demographics
NPI:1295190502
Name:BUNDLE BEHAVIOR
Entity Type:Organization
Organization Name:BUNDLE BEHAVIOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATEASHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CERT HAIR LOSS SPECI
Authorized Official - Phone:913-709-1122
Mailing Address - Street 1:3227 N 103RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-5814
Mailing Address - Country:US
Mailing Address - Phone:913-709-1122
Mailing Address - Fax:
Practice Address - Street 1:1110 N 47TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-1702
Practice Address - Country:US
Practice Address - Phone:913-287-0880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty