MEDICARE: BONAVENTE CORPORATION

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility		CA

General Provider Information

NPI Number	:	1801053277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONAVENTE CORPORATION

Provider Business Mailing Address
First Line	:	6429 N ELLENDALE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-2410
Country	:	US
Telephone Number	:	559-271-9803
Fax Number	:	559-275-8438

Provider Business Practice Location Address
First Line	:	6429 N ELLENDALE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-2410
Country	:	US
Telephone Number	:	559-271-9803
Fax Number	:	559-275-8438

Authorized Official
Title or Position	:	OWNER / PRESIDENT
Name	:	MRS. NIDA A BONAVENTE
Credential	:
Telephone Number	:	559-313-9052

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	08/12/2008

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Directions to “BONAVENTE CORPORATION ” Practice Location

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