Provider Demographics
NPI:1003280512
Name:THE BONIN CLINIC LLC
Entity Type:Organization
Organization Name:THE BONIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:J
Authorized Official - Last Name:BONIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:NP
Authorized Official - Phone:225-570-2010
Mailing Address - Street 1:1215 INDEPENDENCE BLVD
Mailing Address - Street 2:1A
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7390
Mailing Address - Country:US
Mailing Address - Phone:225-570-2010
Mailing Address - Fax:225-570-8573
Practice Address - Street 1:1215 INDEPENDENCE BLVD
Practice Address - Street 2:1A
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-7390
Practice Address - Country:US
Practice Address - Phone:225-570-2010
Practice Address - Fax:225-570-8573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04429261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
466368Medicare PIN