Healthcare Provider Details

I. General information

NPI: 1366973463
Provider Name (Legal Business Name): JEFFREY BONNEVILLE DMSC MS LPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-6962
  • Fax:
Mailing address:
  • Phone: 857-364-6962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOH000281
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPO000194
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211.000165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: