Provider Demographics
NPI:1952409476
Name:GUNDERSEN, BRUCE VAN (DC, FACO)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:VAN
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:DC, FACO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 HOLLADAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2607
Mailing Address - Country:US
Mailing Address - Phone:801-272-8471
Mailing Address - Fax:801-424-2219
Practice Address - Street 1:4211 HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2607
Practice Address - Country:US
Practice Address - Phone:801-272-8471
Practice Address - Fax:801-424-2219
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161820-1202111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid
UT161820-1202OtherSTATE LICENSE
UTT48879Medicare UPIN