Provider Demographics
NPI:1205643160
Name:BONILLA ALEJANDRO, GUSTAVO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:BONILLA ALEJANDRO
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 1:08232 44TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49026-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:08232 44TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:MI
Practice Address - Zip Code:49026-9623
Practice Address - Country:US
Practice Address - Phone:269-360-1756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-14
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant