Provider Demographics
NPI:1942504709
Name:BONAGE MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:BONAGE MEDICAL SUPPLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GOODNEWS
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-278-2000
Mailing Address - Street 1:9101 LIPAN RD
Mailing Address - Street 2:105
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-5568
Mailing Address - Country:US
Mailing Address - Phone:713-278-2000
Mailing Address - Fax:713-278-2002
Practice Address - Street 1:9101 LIPAN RD
Practice Address - Street 2:105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-5568
Practice Address - Country:US
Practice Address - Phone:713-278-2000
Practice Address - Fax:713-278-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2015-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies