Provider Demographics
NPI:1972533016
Name:BONDALE, MANISH (PT)
Entity type:Individual
Prefix:
First Name:MANISH
Middle Name:
Last Name:BONDALE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W. HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT. PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858
Mailing Address - Country:US
Mailing Address - Phone:989-772-0258
Mailing Address - Fax:989-953-4603
Practice Address - Street 1:1500 W. HIGH ST.
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-772-0258
Practice Address - Fax:989-953-4603
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006930225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
30069OtherBCBSM
MI404983397Medicaid
30069OtherBCBSM
MIOP22680Medicare ID - Type Unspecified