Provider Demographics
NPI:1275908642
Name:BONAVISTA OPTICS INC
Entity Type:Organization
Organization Name:BONAVISTA OPTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LABOC, NCLEC
Authorized Official - Phone:424-202-5415
Mailing Address - Street 1:3900 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4316
Mailing Address - Country:US
Mailing Address - Phone:424-404-5415
Mailing Address - Fax:
Practice Address - Street 1:3900 W ALAMEDA AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4316
Practice Address - Country:US
Practice Address - Phone:424-404-5415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL40477332H00000X, 335E00000X
CACL8116332H00000X, 335E00000X
CAD70648332H00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332H00000XSuppliersEyewear Supplier