Provider Demographics
NPI:1164177721
Name:BONITA COSMETIC LLC
Entity Type:Organization
Organization Name:BONITA COSMETIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:ORIBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:IPARRAGUIRRE GONGORA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-931-0024
Mailing Address - Street 1:405 LOCH DEVON DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7820 N ARMENIA AVE STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3852
Practice Address - Country:US
Practice Address - Phone:813-931-0024
Practice Address - Fax:813-931-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-12
Last Update Date:2022-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care