Provider Demographics
NPI:1497246722
Name:LARRY J. BONDERUD, OD
Entity Type:Organization
Organization Name:LARRY J. BONDERUD, OD
Other - Org Name:NORTHERN MONTANA EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:APPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-434-5196
Mailing Address - Street 1:865 OILFIELD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MT
Mailing Address - Zip Code:59474-2702
Mailing Address - Country:US
Mailing Address - Phone:406-434-5196
Mailing Address - Fax:406-434-5197
Practice Address - Street 1:865 OILFIELD AVE STE 1
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MT
Practice Address - Zip Code:59474-2702
Practice Address - Country:US
Practice Address - Phone:406-434-5196
Practice Address - Fax:406-434-5197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARRY J BONDERUD OD, DBA NORTHERN MONTANA EYECARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0481389Medicaid