Healthcare Provider Details

I. General information

NPI: 1720967318
Provider Name (Legal Business Name): ALEC MICHAEL BONAGUIDI RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

8088 W WHITNEY DR
PEORIA AZ
85345-6564
US

V. Phone/Fax

Practice location:
  • Phone: 833-855-9973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: