Healthcare Provider Details

I. General information

NPI: 1508703414
Provider Name (Legal Business Name): BONAFIDE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 W LOGAN BLVD UNIT 3E
CHICAGO IL
60647-1732
US

IV. Provider business mailing address

2501 CHATHAM RD STE N
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 872-265-1588
  • Fax:
Mailing address:
  • Phone: 872-265-1588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BONIFACIO
Title or Position: CEO
Credential: PMHNP-BC
Phone: 872-265-1588