Healthcare Provider Details

I. General information

NPI: 1700278462
Provider Name (Legal Business Name): COLIN BONFIGLIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 21ST AVE S SUITE, 9211
NASHVILLE TN
37232-8590
US

IV. Provider business mailing address

1215 21ST AVE S SUITE, 9211
NASHVILLE TN
37232-8590
US

V. Phone/Fax

Practice location:
  • Phone: 615-936-5040
  • Fax:
Mailing address:
  • Phone: 615-936-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3649
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: