Healthcare Provider Details

I. General information

NPI: 1437301132
Provider Name (Legal Business Name): BON HOMIE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W. LEXINGTON AVE #206
ELKHART IN
46516-2803
US

IV. Provider business mailing address

330 W. LEXINGTON AVE #206
ELKHART IN
46516-2803
US

V. Phone/Fax

Practice location:
  • Phone: 574-333-3308
  • Fax: 574-333-3594
Mailing address:
  • Phone: 574-333-3308
  • Fax: 574-333-3594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MR. BLANTON S. BEATHEA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 574-333-3308