Provider Demographics
NPI:1609002039
Name:BONITA FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:BONITA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL LYNN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-674-8079
Mailing Address - Street 1:9500 BONITA BEACH RD SE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4698
Mailing Address - Country:US
Mailing Address - Phone:239-947-4100
Mailing Address - Fax:239-992-4100
Practice Address - Street 1:9500 BONITA BEACH RD SE
Practice Address - Street 2:SUITE 111
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4698
Practice Address - Country:US
Practice Address - Phone:239-947-4100
Practice Address - Fax:239-992-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization