1740529387 NPI number — MS. CASEY BONANO RD, LD, CEDS-S

Table of content: MS. CASEY BONANO RD, LD, CEDS-S (NPI 1740529387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740529387 NPI number — MS. CASEY BONANO RD, LD, CEDS-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONANO
Provider First Name:
CASEY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CEDS-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740529387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14651 DALLAS PKWY STE 132
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-8864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-454-4801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14651 DALLAS PKWY STE 132
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75254-8864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-454-4801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT82114 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com