Provider Demographics
NPI:1477034296
Name:BONAVISTA OPTICS INCORPORATED
Entity Type:Organization
Organization Name:BONAVISTA OPTICS INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:808-634-5118
Mailing Address - Street 1:610 RUNNYMEDE RD
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3322
Mailing Address - Country:US
Mailing Address - Phone:937-250-1810
Mailing Address - Fax:937-250-1812
Practice Address - Street 1:610 RUNNYMEDE RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:OH
Practice Address - Zip Code:45419-3322
Practice Address - Country:US
Practice Address - Phone:937-250-1810
Practice Address - Fax:937-250-1812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-29
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FC0801X
OHOP.017041-SC332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty