Provider Demographics
NPI:1922096999
Name:BONITA COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:BONITA COMMUNITY HEALTH CENTER INC
Other - Org Name:BONITA COMMUNITY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-949-6115
Mailing Address - Street 1:3501 HEALTH CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8127
Mailing Address - Country:US
Mailing Address - Phone:239-949-1050
Mailing Address - Fax:239-949-6111
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-949-1050
Practice Address - Fax:239-949-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2728516 00Medicaid
FL274894OtherAVMED
FL45737OtherBCBS FLORIDA
FL925030OtherAETNA
FLK2402Medicare PIN