Provider Demographics
NPI:1740316348
Name:BONDAREV, ANATOLY (DC)
Entity type:Individual
Prefix:
First Name:ANATOLY
Middle Name:
Last Name:BONDAREV
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 1:1019 N FAIRFAX AVE
Mailing Address - Street 2:101
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6160
Mailing Address - Country:US
Mailing Address - Phone:323-650-5530
Mailing Address - Fax:323-650-5539
Practice Address - Street 1:1019 N FAIRFAX AVE
Practice Address - Street 2:101
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6160
Practice Address - Country:US
Practice Address - Phone:323-650-5530
Practice Address - Fax:323-650-5539
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21902111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21902OtherSTATE LICENSE NUMBER
CADC21902OtherSTATE LICENSE NUMBER
CADC21902Medicare ID - Type Unspecified