MEDICARE: BONVITA PEDIATRIC THERAPY AND LACTATION, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	174N00000X	Lactation Consultant (Non-RN)
2	225XF0002X	Feeding, Eating & Swallowing Occupational Therapist
3	225XM0800X	Mental Health Occupational Therapist
4	225XP0200X	Pediatric Occupational Therapist
5	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1336928357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONVITA PEDIATRIC THERAPY AND LACTATION, LLC

Provider Business Mailing Address
First Line	:	1610 N COLUMBIA AVE
Second Line	:
City	:	SEWARD
State	:	NE
Zip	:	68434-1111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1610 N COLUMBIA AVE
Second Line	:
City	:	SEWARD
State	:	NE
Zip	:	68434-1111
Country	:	US
Telephone Number	:	402-523-2128
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	DR. TEDDIE GENTER
Credential	:	OTR/L
Telephone Number	:	562-417-6068

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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