Healthcare Provider Details

I. General information

NPI: 1265099295
Provider Name (Legal Business Name): MICHAEL L BONILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 VISTA WAY E
OCEANSIDE CA
92056
US

IV. Provider business mailing address

3998 VISTA WAY STE E
OCEANSIDE CA
92056-4514
US

V. Phone/Fax

Practice location:
  • Phone: 760-295-9830
  • Fax: 760-295-9866
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: