Provider Demographics
NPI:1942496047
Name:MARK BONTREGER INC
Entity Type:Organization
Organization Name:MARK BONTREGER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:BONTREGER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:605-882-0800
Mailing Address - Street 1:525 5TH ST SE
Mailing Address - Street 2:SUITE L-13
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4940
Mailing Address - Country:US
Mailing Address - Phone:605-882-0800
Mailing Address - Fax:605-882-0861
Practice Address - Street 1:525 5TH ST SE
Practice Address - Street 2:SUITE L-13
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4940
Practice Address - Country:US
Practice Address - Phone:605-882-0800
Practice Address - Fax:605-882-0861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS40195Medicare PIN