Provider Demographics
NPI:1437228830
Name:PAUL V BONARRIGO
Entity Type:Organization
Organization Name:PAUL V BONARRIGO
Other - Org Name:SPORTS AND BACK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:V
Authorized Official - Last Name:BONARRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:979-776-2225
Mailing Address - Street 1:2011-A E VILLA MARIA
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:979-776-2225
Mailing Address - Fax:979-776-7945
Practice Address - Street 1:2011A E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2541
Practice Address - Country:US
Practice Address - Phone:979-776-2225
Practice Address - Fax:979-776-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1005635174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0092QSOtherBLUE CROSS
TX0092QSOtherBLUE CROSS
TX650087Medicare ID - Type Unspecified