Healthcare Provider Details

I. General information

NPI: 1194635136
Provider Name (Legal Business Name): EDWARD BONK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 WALKER ST
MANCHESTER CT
06040-4330
US

IV. Provider business mailing address

66 WALKER ST
MANCHESTER CT
06040-4330
US

V. Phone/Fax

Practice location:
  • Phone: 860-682-4048
  • Fax:
Mailing address:
  • Phone: 860-682-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003612
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: