Provider Demographics
NPI:1689192171
Name:BONGCO, ALFEA MARIE MORENO (PTA)
Entity Type:Individual
Prefix:
First Name:ALFEA MARIE
Middle Name:MORENO
Last Name:BONGCO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BUCKSON CT
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-3056
Mailing Address - Country:US
Mailing Address - Phone:310-866-7276
Mailing Address - Fax:
Practice Address - Street 1:810 S BROOM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4245
Practice Address - Country:US
Practice Address - Phone:302-652-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0001068225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant