Provider Demographics
NPI:1922705607
Name:BONILLA, ELMER
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:
Last Name:BONILLA
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 1:191 PRENTICE TRL
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-9827
Mailing Address - Country:US
Mailing Address - Phone:970-456-9965
Mailing Address - Fax:
Practice Address - Street 1:191 PRENTICE TRL
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-9827
Practice Address - Country:US
Practice Address - Phone:970-456-9965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver