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General NPI Number Information
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NPI Number | 1477728970
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Entity Type | Organization
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Legal Business Name | NILAH NICOLE BONHAM OD PC
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Dates
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Enumeration Date | 04/25/2008
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Last Update Date | 04/25/2008
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Provider Practice Location Address
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Address Line | 325 W NATIONAL AVE
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City | BRAZIL
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State | IN
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Zip | 47834-2542
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Country | US
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Telephone | 812-443-0060
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Fax |
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Provider Business Mailing Address
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Address Line | 325 W NATIONAL AVE
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City | BRAZIL
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State | IN
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Zip | 47834-2542
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Country | US
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Telephone | 812-443-0060
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. NILAH NICOLE BONHAM
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Credential | OD
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Telephone | 812-443-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 6024820001
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License Number State | IN
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