MEDICARE: BONAVISTA OPTICS INC

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	332H00000X	Eyewear Supplier	SL40477	CA
2	332H00000X	Eyewear Supplier	CL8116	CA
3	335E00000X	Prosthetic/Orthotic Supplier	CL8116	CA
4	335E00000X	Prosthetic/Orthotic Supplier	SL40477	CA
5	332H00000X	Eyewear Supplier	D70648	CA
6	335E00000X	Prosthetic/Orthotic Supplier	D70648	CA

General Provider Information

NPI Number	:	1275908642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONAVISTA OPTICS INC

Provider Business Mailing Address
First Line	:	3900 W ALAMEDA AVE
Second Line	:	SUITE 1200
City	:	BURBANK
State	:	CA
Zip	:	91505-4316
Country	:	US
Telephone Number	:	424-404-5415
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 W ALAMEDA AVE
Second Line	:	SUITE 1200
City	:	BURBANK
State	:	CA
Zip	:	91505-4316
Country	:	US
Telephone Number	:	424-404-5415
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, OPTICIAN
Name	:	MRS. BONNIE J ASHLEY
Credential	:	LABOC, NCLEC
Telephone Number	:	424-202-5415

Provider Enumeration Date	:	12/10/2015
Last Update Date	:	05/01/2017

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Directions to “BONAVISTA OPTICS INC ” Practice Location

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