MEDICARE: GERALD BONILLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	AS2624	FL

General Provider Information

NPI Number	:	1164609285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALD BONILLA

Provider Business Mailing Address
First Line	:	5000 CHESHIRE LN N
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55446-3706
Country	:	US
Telephone Number	:	888-333-9152
Fax Number	:	763-268-4240

Provider Business Practice Location Address
First Line	:	2320 DAIRY RD
Second Line	:	SUITE 101
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-5208
Country	:	US
Telephone Number	:	321-725-4948
Fax Number	:	321-725-0831

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

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