1104202829 NPI number — MR. JOSE ALBERTO BONILLA PADILLA AMFT 138707

Table of content: MR. JOSE ALBERTO BONILLA PADILLA AMFT 138707 (NPI 1104202829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104202829 NPI number — MR. JOSE ALBERTO BONILLA PADILLA AMFT 138707

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA PADILLA
Provider First Name:
JOSE
Provider Middle Name:
ALBERTO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AMFT 138707
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BONILLA PADILLA
Provider Other First Name:
JOSE
Provider Other Middle Name:
ALBERTO
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
AMFT138707
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104202829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 S EREMLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91723-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-966-1577
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 S EREMLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91723-3186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-966-1577
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2015

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: 106H00000X , with the licence number:  138707 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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