Provider Demographics
NPI:1427187681
Name:MANDEVILLE, BONITA B (DC)
Entity Type:Individual
Prefix:DR
First Name:BONITA
Middle Name:B
Last Name:MANDEVILLE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17007 E COLONY DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-4672
Mailing Address - Country:US
Mailing Address - Phone:480-837-3188
Mailing Address - Fax:480-836-9009
Practice Address - Street 1:17007 E COLONY DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-4672
Practice Address - Country:US
Practice Address - Phone:480-837-3188
Practice Address - Fax:480-836-9009
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7281111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z71827Medicare ID - Type Unspecified
AZZ71827Medicare UPIN