Healthcare Provider Details

I. General information

NPI: 1851376370
Provider Name (Legal Business Name): BONNIEVILLE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 BONNIEVILLE RD
STILLWATER PA
17878-9211
US

IV. Provider business mailing address

477 BONNIEVILLE RD
STILLWATER PA
17878-9211
US

V. Phone/Fax

Practice location:
  • Phone: 570-864-3174
  • Fax: 570-864-3897
Mailing address:
  • Phone: 570-864-3174
  • Fax: 570-864-3897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number022802
License Number StatePA

VIII. Authorized Official

Name: MR. JAMES K. BONHAM JR.
Title or Position: PRESIDENT
Credential:
Phone: 570-864-3174