Healthcare Provider Details

I. General information

NPI: 1104461649
Provider Name (Legal Business Name): BONNER GENERAL HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 N 3RD AVE STE 110
SANDPOINT ID
83864-1511
US

IV. Provider business mailing address

PO BOX 1343
SANDPOINT ID
83864-0863
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-1011
  • Fax: 208-265-6271
Mailing address:
  • Phone: 208-265-1158
  • Fax: 208-265-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN HENNESSY
Title or Position: CEO
Credential:
Phone: 208-265-1100