Provider Demographics
NPI:1114736899
Name:BOUNTIFUL
Entity type:Organization
Organization Name:BOUNTIFUL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-259-0289
Mailing Address - Street 1:25 JEFFERSON WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5953
Mailing Address - Country:US
Mailing Address - Phone:201-259-0289
Mailing Address - Fax:973-215-2052
Practice Address - Street 1:25 JEFFERSON WAY STE 102
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5953
Practice Address - Country:US
Practice Address - Phone:201-259-0289
Practice Address - Fax:973-215-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals