Healthcare Provider Details

I. General information

NPI: 1700772498
Provider Name (Legal Business Name): TERESA BONILLA SUPPORT SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 W 8TH ST
SAN PEDRO CA
90731-3120
US

IV. Provider business mailing address

590 W 8TH ST
SAN PEDRO CA
90731-3120
US

V. Phone/Fax

Practice location:
  • Phone: 310-831-2358
  • Fax:
Mailing address:
  • Phone: 310-831-2358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-WTVSYE
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: