Provider Demographics
NPI:1003578006
Name:BONILLA, EDWARD XAVIER (OT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:XAVIER
Last Name:BONILLA
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-200-3620
Mailing Address - Fax:
Practice Address - Street 1:3989 W STETSON AVE STE 105
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9697
Practice Address - Country:US
Practice Address - Phone:951-652-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22784225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist