Provider Demographics
NPI:1043686488
Name:BONIFAZI, GIANCARLO (PT)
Entity type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:
Last Name:BONIFAZI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 WINSTON PLZ
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1508
Practice Address - Country:US
Practice Address - Phone:708-483-0072
Practice Address - Fax:708-551-3982
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist