Provider Demographics
NPI:1881389518
Name:BONILLA, SEBASTIAN (LAC)
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 SUMMER ST APT 3103
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-4385
Mailing Address - Country:US
Mailing Address - Phone:832-970-3266
Mailing Address - Fax:
Practice Address - Street 1:6415 SAN FELIPE ST STE C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-2700
Practice Address - Country:US
Practice Address - Phone:832-975-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02070171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist