Provider Demographics
NPI:1073728770
Name:BONITA HOUSE, INC.
Entity Type:Organization
Organization Name:BONITA HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:EVON
Authorized Official - Last Name:WEISSBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:105-931-9505
Mailing Address - Street 1:1919 ADDISON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1143
Mailing Address - Country:US
Mailing Address - Phone:510-899-7445
Mailing Address - Fax:510-647-9408
Practice Address - Street 1:1605 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1215
Practice Address - Country:US
Practice Address - Phone:510-923-1099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2023-08-26
Deactivation Date:2023-03-17
Deactivation Code:
Reactivation Date:2023-07-24
Provider Licenses
StateLicense IDTaxonomies
CA01113251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01113Medicaid