MEDICARE: BONITA COSMETIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1164177721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONITA COSMETIC LLC

Provider Business Mailing Address
First Line	:	405 LOCH DEVON DR
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33548-4282
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7820 N ARMENIA AVE STE B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-3852
Country	:	US
Telephone Number	:	813-931-0024
Fax Number	:	813-931-0026

Authorized Official
Title or Position	:	AMBR
Name	:	ORIBERTO IPARRAGUIRRE GONGORA
Credential	:	APRN
Telephone Number	:	813-931-0024

Provider Enumeration Date	:	02/12/2022
Last Update Date	:	02/12/2022

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Directions to “BONITA COSMETIC LLC ” Practice Location

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