Healthcare Provider Details

I. General information

NPI: 1063992014
Provider Name (Legal Business Name): BONIFACIO CORONEL FONTANILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 SCENIC RIDGE DR
CHINO HILLS CA
91709
US

IV. Provider business mailing address

3440 E LA PALMA AVE
ANAHEIM CA
92806-2020
US

V. Phone/Fax

Practice location:
  • Phone: 909-210-1931
  • Fax:
Mailing address:
  • Phone: 714-644-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number14762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: