Provider Demographics
NPI:1689894107
Name:BONENBERGER, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BONENBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 N CARBON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1067
Mailing Address - Country:US
Mailing Address - Phone:618-997-5856
Mailing Address - Fax:618-997-5953
Practice Address - Street 1:1108 N CARBON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1067
Practice Address - Country:US
Practice Address - Phone:618-997-5856
Practice Address - Fax:618-997-5953
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2798237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist