MEDICARE: VIVIANA BONANSEA

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	21087	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14-06213464	OTHER	CA	NPA

General Provider Information

NPI Number	:	1548672199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIANA BONANSEA

Provider Business Mailing Address
First Line	:	PO BOX 12834
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90295-3834
Country	:	US
Telephone Number	:	310-800-6808
Fax Number	:

Provider Business Practice Location Address
First Line	:	1527 21ST ST
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-4038
Country	:	US
Telephone Number	:	310-800-6808
Fax Number	:

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

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	05/29/2014

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Directions to “ VIVIANA BONANSEA ” Practice Location

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