1710008198 NPI number — GLENN R BONIFIELD JR

Table of content: (NPI 1710008198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710008198 NPI number — GLENN R BONIFIELD JR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENN R BONIFIELD JR
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1710008198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 280
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38006-0280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-663-2077
Provider Business Mailing Address Fax Number:
731-663-2077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38006-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-663-2077
Provider Business Practice Location Address Fax Number:
731-663-2077
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BONIFIELD
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
731-663-2077

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 00000120 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2095063 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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