Healthcare Provider Details

I. General information

NPI: 1992901763
Provider Name (Legal Business Name): BONNIE MEVIS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 WASHINGTON ST
LA PORTE IN
46350-3221
US

IV. Provider business mailing address

421 W MADISON ST
CULVER IN
46511-1419
US

V. Phone/Fax

Practice location:
  • Phone: 219-326-2397
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number05008814A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: