=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710197686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENIUM MEDICAL CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 01/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 CALLE MUNOZ RIVERA AGUAS BUENAS
-----------------------------------------------------
City | AGUAS BUENAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00703-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-732-7424
-----------------------------------------------------
Fax | 787-757-6306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 CALLE MUNOZ RIVERA AGUAS BUENAS
-----------------------------------------------------
City | AGUAS BUENAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00703-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-732-7424
-----------------------------------------------------
Fax | 787-757-6306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDWIN BONILLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-732-7424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 11614
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------