Provider Demographics
NPI:1659063105
Name:BONILLA, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-1102
Mailing Address - Country:US
Mailing Address - Phone:541-567-5283
Mailing Address - Fax:541-567-5407
Practice Address - Street 1:1350 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1102
Practice Address - Country:US
Practice Address - Phone:541-567-5283
Practice Address - Fax:541-567-5407
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician