Provider Demographics
NPI:1851376370
Name:BONNIEVILLE INC.
Entity Type:Organization
Organization Name:BONNIEVILLE INC.
Other - Org Name:BONHAM NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:570-864-3174
Mailing Address - Street 1:477 BONNIEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:PA
Mailing Address - Zip Code:17878-9211
Mailing Address - Country:US
Mailing Address - Phone:570-864-3174
Mailing Address - Fax:570-864-3897
Practice Address - Street 1:477 BONNIEVILLE RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:PA
Practice Address - Zip Code:17878-9211
Practice Address - Country:US
Practice Address - Phone:570-864-3174
Practice Address - Fax:570-864-3897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA022802314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031076580001Medicaid
PA395654Medicare ID - Type Unspecified