=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083960108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONAVENTURE MEDICAL FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2012
-----------------------------------------------------
Last Update Date | 07/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 864 W STEARNS RD SUITE 106
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-252-6098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 864 W STEARNS RD SUITE 106
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-252-6098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REG. DIETITIAN/PROGRAM COORDINATOR
-----------------------------------------------------
Name | MARGARET ROSE CONNOR
-----------------------------------------------------
Credential | R.D., L.D.N.
-----------------------------------------------------
Telephone | 847-252-6098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 164005616
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------