Provider Demographics
NPI:1144410275
Name:BONAZZOLI, ROBIN J (LIC AC)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:J
Last Name:BONAZZOLI
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HUDSON RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01740-1417
Mailing Address - Country:US
Mailing Address - Phone:978-779-9872
Mailing Address - Fax:
Practice Address - Street 1:563 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MA
Practice Address - Zip Code:01740-1300
Practice Address - Country:US
Practice Address - Phone:978-779-9872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226472171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist