Provider Demographics
NPI:1639261308
Name:BONAVITO LARRAGOITE, GINA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:MARIE
Last Name:BONAVITO LARRAGOITE
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 1:3624 W ANTHEM WAY
Mailing Address - Street 2:SUITE C 110
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086
Mailing Address - Country:US
Mailing Address - Phone:623-551-9950
Mailing Address - Fax:623-551-2454
Practice Address - Street 1:3624 W ANTHEM WAY
Practice Address - Street 2:SUITE C 110
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086
Practice Address - Country:US
Practice Address - Phone:623-551-9950
Practice Address - Fax:623-551-2454
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0939890OtherBLUE CROSS BLUE SHIELD
AZAZ0939890OtherBLUE CROSS BLUE SHIELD
AZ77720Medicare ID - Type Unspecified