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NPI Code Detail

MEDICARE: ANNEMARIE MIRANDA BONILLA PT, DPT

MEDICARE: ANNEMARIE MIRANDA BONILLA PT, DPT
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
12251P0200XPediatric Physical Therapist301279CA

General Provider Information

NPI Number : 1477210466
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANNEMARIE MIRANDA BONILLA PT, DPT
Provider Business Mailing Address
First Line : 16055 RAYEN ST
Second Line :
City : NORTH HILLS
State : CA
Zip : 91343-4848
Country : US
Telephone Number : 415-328-0915
Fax Number :
Provider Business Practice Location Address
First Line : 11460 W WASHINGTON BLVD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90066-6030
Country : US
Telephone Number : 310-337-7115
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/24/2021
Last Update Date : 02/14/2025

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