Provider Demographics
NPI:1174984157
Name:BUNDOR, RACHEAL (CEO)
Entity type:Individual
Prefix:
First Name:RACHEAL
Middle Name:
Last Name:BUNDOR
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:UPPER CHICHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19061-3523
Mailing Address - Country:US
Mailing Address - Phone:267-408-2202
Mailing Address - Fax:484-229-1188
Practice Address - Street 1:2604 JOHNSON RD
Practice Address - Street 2:
Practice Address - City:UPPER CHICHESTER
Practice Address - State:PA
Practice Address - Zip Code:19061-3523
Practice Address - Country:US
Practice Address - Phone:267-408-2202
Practice Address - Fax:484-229-1188
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACER-00091663373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACER-00091663Medicaid