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General NPI Number Information
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NPI Number | 1992563969
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Entity Type | Organization
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Legal Business Name | BONITA EMERGENCY GROUP, LLC
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Dates
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Enumeration Date | 03/13/2024
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Last Update Date | 03/13/2024
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Provider Practice Location Address
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Address Line | 1314 19TH AVE
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City | MERIDIAN
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State | MS
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Zip | 39301-4116
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Country | US
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Telephone | 601-483-0011
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Fax | 601-483-4384
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Provider Business Mailing Address
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Address Line | 200 CORPORATE BLVD
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City | LAFAYETTE
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State | LA
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Zip | 70508-3870
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Country | US
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Telephone | 800-893-9698
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Fax |
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Authorized Official
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Title or Position | VP OF CONTRACTING
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Name | LISHA C FALK
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Credential |
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Telephone | 337-609-1221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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