Provider Demographics
NPI:1639612484
Name:BONITA MEDICAL CARE CENTER,INC
Entity Type:Organization
Organization Name:BONITA MEDICAL CARE CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-405-7721
Mailing Address - Street 1:1320 MARIPOSA CIR APT 104
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-7231
Mailing Address - Country:US
Mailing Address - Phone:239-273-1971
Mailing Address - Fax:
Practice Address - Street 1:26455 OLD 41 RD
Practice Address - Street 2:SUITE 18
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-5124
Practice Address - Country:US
Practice Address - Phone:239-405-7721
Practice Address - Fax:239-405-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHV2572Medicaid
FLHV2572Medicaid