Provider Demographics
NPI:1720779119
Name:AMUNDSON, HENRY GERHARD III
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:GERHARD
Last Name:AMUNDSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9756 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1615
Mailing Address - Country:US
Mailing Address - Phone:949-702-7467
Mailing Address - Fax:
Practice Address - Street 1:9756 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1615
Practice Address - Country:US
Practice Address - Phone:949-702-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies