Provider Demographics
NPI:1679007983
Name:BOMZE, ILENE
Entity Type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:
Last Name:BOMZE
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 1:75 TOLL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3074
Mailing Address - Country:US
Mailing Address - Phone:215-364-5608
Mailing Address - Fax:
Practice Address - Street 1:75 TOLL DR
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3074
Practice Address - Country:US
Practice Address - Phone:215-364-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA443356246OtherPASSPORT