Provider Demographics
NPI:1598225898
Name:BONNER MEDICAL HAIR GROUP INCORPORATED
Entity Type:Organization
Organization Name:BONNER MEDICAL HAIR GROUP INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:256-457-3071
Mailing Address - Street 1:4310 BRONTE LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4981
Mailing Address - Country:US
Mailing Address - Phone:256-457-3071
Mailing Address - Fax:
Practice Address - Street 1:4600 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3075
Practice Address - Country:US
Practice Address - Phone:256-457-3071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty