Provider Demographics
NPI:1871695288
Name:BONUM INC
Entity type:Organization
Organization Name:BONUM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-375-2171
Mailing Address - Street 1:320 SOUTH SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:GRAYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62844-1567
Mailing Address - Country:US
Mailing Address - Phone:618-375-2171
Mailing Address - Fax:618-375-7756
Practice Address - Street 1:320 S 2ND ST
Practice Address - Street 2:
Practice Address - City:GRAYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62844-1527
Practice Address - Country:US
Practice Address - Phone:618-375-2171
Practice Address - Fax:618-375-7756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0019356313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
207810Medicare ID - Type Unspecified