Provider Demographics
NPI:1275715534
Name:BON NOLA, M.D. , LLC
Entity Type:Organization
Organization Name:BON NOLA, M.D. , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOUNSAVATH
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-689-6004
Mailing Address - Street 1:1431 S BLUFFVIEW DR
Mailing Address - Street 2:S-116
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-3039
Mailing Address - Country:US
Mailing Address - Phone:316-689-6004
Mailing Address - Fax:
Practice Address - Street 1:804 S OLIVER AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-2329
Practice Address - Country:US
Practice Address - Phone:316-689-6004
Practice Address - Fax:316-613-2934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0424718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty