=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538936521
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRIMO BONILLA OTR/L, HT, PAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2023
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 670 9TH ST STE 4
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-232-5452
-----------------------------------------------------
Fax | 707-306-7112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 670 9TH ST STE 4
-----------------------------------------------------
City | ARCATA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95521-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-232-5452
-----------------------------------------------------
Fax | 707-306-7112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 24672
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------