Provider Demographics
NPI:1235518606
Name:BONAIME, RANDALL
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:BONAIME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9825 MAGNOLIA AVE
Mailing Address - Street 2:SUITE B, PMB 322
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3562
Mailing Address - Country:US
Mailing Address - Phone:866-481-5361
Mailing Address - Fax:
Practice Address - Street 1:9990 COUNTY FARM RD
Practice Address - Street 2:SUITE 6
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3542
Practice Address - Country:US
Practice Address - Phone:866-481-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA317810163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760651178Medicaid