Healthcare Provider Details

I. General information

NPI: 1366973463
Provider Name (Legal Business Name): JEFFREY BONNEVILLE DMSC MS L/CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3214 NW 110TH TERRACE 3214 NW 110TH TERRACE
GAINESVILLE FL
32606-4977
US

IV. Provider business mailing address

3214 NW 110TH TERRACE GAINESVILLE FL 32606 1ST FLOOR
GAINESVILLE FL
32606-4977
US

V. Phone/Fax

Practice location:
  • Phone: 516-582-8336
  • Fax:
Mailing address:
  • Phone: 516-582-8336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number221-000165
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOH000281
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000165
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT394
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPO000194
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: