MEDICARE: BONIFAY PHYSICAL THERAPY

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	PT14591	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y921V	OTHER	FL	BCBS FL PROVIDER #

General Provider Information

NPI Number	:	1649311879
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONIFAY PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	1812 S WAUKESHA ST
Second Line	:
City	:	BONIFAY
State	:	FL
Zip	:	32425-3100
Country	:	US
Telephone Number	:	850-547-4646
Fax Number	:	850-547-4766

Provider Business Practice Location Address
First Line	:	1812 S WAUKESHA ST
Second Line	:
City	:	BONIFAY
State	:	FL
Zip	:	32425-3100
Country	:	US
Telephone Number	:	850-547-4646
Fax Number	:	850-547-4766

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. RUBEN ALONZO LAUREL
Credential	:
Telephone Number	:	850-638-3387

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	05/16/2019

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Directions to “BONIFAY PHYSICAL THERAPY ” Practice Location

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