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General NPI Number Information
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NPI Number | 1710263074
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Entity Type | Organization
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Legal Business Name | BONACCI OPTOMETRY INC., P.C.
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Dates
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Enumeration Date | 10/31/2011
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Last Update Date | 10/31/2011
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Provider Practice Location Address
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Address Line | 4611 HIGHWAY 29 S
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City | ALEXANDRIA
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State | MN
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Zip | 56308-6175
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Country | US
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Telephone | 320-762-4044
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Fax | 320-762-4046
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Provider Business Mailing Address
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Address Line | 11 GLENVIEW LOOP
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City | SAINT CLOUD
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State | MN
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Zip | 56303-4865
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Country | US
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Telephone | 407-415-7551
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Fax | 320-762-4046
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Authorized Official
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Title or Position | OPTOMETRY
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Name | DR. DEREK JOHN BONACCI
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Credential | O.D.
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Telephone | 407-415-7551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3170
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License Number State | MN
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