Healthcare Provider Details

I. General information

NPI: 1144058413
Provider Name (Legal Business Name): ELENA MARIE BONK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20500 BELSHAW AVE # EXCA1377
CARSON CA
90746-3506
US

IV. Provider business mailing address

20500 BELSHAW AVE # EXCA1377
CARSON CA
90746-3506
US

V. Phone/Fax

Practice location:
  • Phone: 855-442-5885
  • Fax:
Mailing address:
  • Phone: 554-425-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number13041
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2370
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: