Provider Demographics
NPI:1144399494
Name:BONFIM, SAMMY (PT)
Entity Type:Individual
Prefix:
First Name:SAMMY
Middle Name:
Last Name:BONFIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PLANTATION CENTRE DR S
Mailing Address - Street 2:BLDG 900
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2079
Mailing Address - Country:US
Mailing Address - Phone:478-757-2255
Mailing Address - Fax:478-477-2977
Practice Address - Street 1:125 PLANTATION CENTRE DR S
Practice Address - Street 2:BLDG 900
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2079
Practice Address - Country:US
Practice Address - Phone:478-757-2255
Practice Address - Fax:478-477-2977
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007119225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA007119OtherSTATE LISC NUMBER