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General NPI Number Information
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NPI Number | 1982576039
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Entity Type | Individual
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Provider Name | JEREMY BONILLA
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Gender | Male
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Dates
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Enumeration Date | 09/18/2025
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Last Update Date | 09/18/2025
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Provider Practice Location Address
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Address Line | 1508 W AVENUE J
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City | TEMPLE
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State | TX
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Zip | 76504-5390
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Country | US
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Telephone | 254-771-3374
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Fax |
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Provider Business Mailing Address
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Address Line | 10910 LITTLE GAP CT
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City | SUGAR LAND
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State | TX
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Zip | 77498-0946
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 44728673
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License Number State | TX
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