Provider Demographics
NPI:1689036444
Name:BONDERUD, HEIDI (DC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:BONDERUD
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 1:1564 PARKER BLVD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-8730
Mailing Address - Country:US
Mailing Address - Phone:716-534-2873
Mailing Address - Fax:
Practice Address - Street 1:1564 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-8730
Practice Address - Country:US
Practice Address - Phone:207-240-3782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012440-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor