Healthcare Provider Details

I. General information

NPI: 1487569224
Provider Name (Legal Business Name): MARY T BONSALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 248TH ST
LOMITA CA
90717-1333
US

IV. Provider business mailing address

1730 248TH ST
LOMITA CA
90717-1333
US

V. Phone/Fax

Practice location:
  • Phone: 310-344-6450
  • Fax:
Mailing address:
  • Phone: 310-344-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberBL-LIC-034030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: