MEDICARE: BONITA FAMILY CARE, 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	207Q00000X	Family Medicine Physician	ME63084	FL

General Provider Information

NPI Number	:	1902912850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONITA FAMILY CARE, INC

Provider Business Mailing Address
First Line	:	PO BOX 366734
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34136-6734
Country	:	US
Telephone Number	:	239-992-4344
Fax Number	:	239-992-5042

Provider Business Practice Location Address
First Line	:	10459 REYNOLDS ST
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-5535
Country	:	US
Telephone Number	:	239-992-4344
Fax Number	:	239-992-5042

Authorized Official
Title or Position	:	OWNER
Name	:	DOMINGO FELICIANO
Credential	:	MD
Telephone Number	:	239-992-4344

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	06/19/2008

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