MEDICARE: MR. RYAN SAMUEL BONILLA MPT

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	225100000X	Physical Therapist	PT 22295	FL

General Provider Information

NPI Number	:	1245337906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN SAMUEL BONILLA MPT

Provider Business Mailing Address
First Line	:	9873 BAYWINDS DR
Second Line	:	UNIT 5211
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-1845
Country	:	US
Telephone Number	:	561-906-0607
Fax Number	:

Provider Business Practice Location Address
First Line	:	3898 VIA POINCIANA
Second Line	:	SUITE 12
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-2951
Country	:	US
Telephone Number	:	561-966-9273
Fax Number	:	561-966-8810

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	07/08/2007

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