Healthcare Provider Details

I. General information

NPI: 1275142598
Provider Name (Legal Business Name): BONNIE DONAIRE DEL ROSARIO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LEIGH AVE
ANNA IL
62906-2232
US

IV. Provider business mailing address

137 W VIENNA ST APT 2A
ANNA IL
62906-1656
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-1506
  • Fax:
Mailing address:
  • Phone: 618-697-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070021275
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: