Provider Demographics
NPI:1740375567
Name:BONOMO, GREGORY ALLEN (DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:BONOMO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13007 BERMUDA AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4563
Mailing Address - Country:US
Mailing Address - Phone:626-378-5827
Mailing Address - Fax:
Practice Address - Street 1:9120 CHURCH ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-2103
Practice Address - Country:US
Practice Address - Phone:626-378-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25391225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist