Provider Demographics
NPI:1417566415
Name:BONNIEVIEW-OVERTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:BONNIEVIEW-OVERTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-398-4157
Mailing Address - Street 1:909 MORRISON DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6079
Mailing Address - Country:US
Mailing Address - Phone:972-342-6581
Mailing Address - Fax:214-398-4326
Practice Address - Street 1:3507 BONNIE VIEW RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-4704
Practice Address - Country:US
Practice Address - Phone:214-398-4157
Practice Address - Fax:214-398-4326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-26
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center