Provider Demographics
NPI:1710263074
Name:BONACCI OPTOMETRY INC., P.C.
Entity Type:Organization
Organization Name:BONACCI OPTOMETRY INC., P.C.
Other - Org Name:DEREK BONACCI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BONACCI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-415-7551
Mailing Address - Street 1:11 GLENVIEW LOOP
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4865
Mailing Address - Country:US
Mailing Address - Phone:407-415-7551
Mailing Address - Fax:320-762-4046
Practice Address - Street 1:4611 HIGHWAY 29 S
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-6175
Practice Address - Country:US
Practice Address - Phone:320-762-4044
Practice Address - Fax:320-762-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty