Healthcare Provider Details

I. General information

NPI: 1780829812
Provider Name (Legal Business Name): BONNIE J WATKINS OTR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 STONEGATE CT
BEDFORD TX
76022-6651
US

IV. Provider business mailing address

128 STONEGATE CT
BEDFORD TX
76022-6651
US

V. Phone/Fax

Practice location:
  • Phone: 817-929-5792
  • Fax:
Mailing address:
  • Phone: 817-929-5792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number101183
License Number StateTX

VIII. Authorized Official

Name: MISS BONNIE JEAN WATKINS
Title or Position: PRESIDENT
Credential: OTR
Phone: 817-929-5792