Provider Demographics
NPI:1740384452
Name:BONDURANT, BRENT LEVI (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LEVI
Last Name:BONDURANT
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 1:212 EAST IVINSON
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070
Mailing Address - Country:US
Mailing Address - Phone:307-742-4332
Mailing Address - Fax:307-745-1536
Practice Address - Street 1:212 E IVINSON AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3039
Practice Address - Country:US
Practice Address - Phone:307-742-4332
Practice Address - Fax:307-745-1536
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor