Healthcare Provider Details

I. General information

NPI: 1477034296
Provider Name (Legal Business Name): BONAVISTA OPTICS INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 RUNNYMEDE RD
OAKWOOD OH
45419-3322
US

IV. Provider business mailing address

610 RUNNYMEDE RD
OAKWOOD OH
45419-3322
US

V. Phone/Fax

Practice location:
  • Phone: 937-250-1810
  • Fax: 937-250-1812
Mailing address:
  • Phone: 937-250-1810
  • Fax: 937-250-1812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOP.017041-SC
License Number StateOH

VIII. Authorized Official

Name: MRS. BONNIE J ASHLEY
Title or Position: PRESIDENT
Credential: LABOC NCLEC
Phone: 808-634-5118