Healthcare Provider Details

I. General information

NPI: 1578487260
Provider Name (Legal Business Name): LISA MARIE BONILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E MOORE AVE
TERRELL TX
75160-3208
US

IV. Provider business mailing address

4547 CORREGIDOR ST
DALLAS TX
75216-5015
US

V. Phone/Fax

Practice location:
  • Phone: 469-677-0029
  • Fax: 214-792-9697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16996
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: