Provider Demographics
NPI:1245452838
Name:BONVILLIAN, TARA JENNIFER (DC)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:JENNIFER
Last Name:BONVILLIAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 47TH STREET, SUITE F-2
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-440-0979
Mailing Address - Fax:303-440-0993
Practice Address - Street 1:3005 47TH STREET, SUITE F-2
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-440-0979
Practice Address - Fax:303-440-0993
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor