Provider Demographics
NPI:1811228000
Name:BONAVITA, ROCCO JOHN (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROCCO
Middle Name:JOHN
Last Name:BONAVITA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 JETMORE PL
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7812
Mailing Address - Country:US
Mailing Address - Phone:917-723-8278
Mailing Address - Fax:
Practice Address - Street 1:28 JETMORE PL
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-7812
Practice Address - Country:US
Practice Address - Phone:917-723-8278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00427501171100000X
NY004275-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist