1578062014 NPI number — MISS LISA MARIE BONAVENTURA LMT

Table of content: MISS LISA MARIE BONAVENTURA LMT (NPI 1578062014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578062014 NPI number — MISS LISA MARIE BONAVENTURA LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONAVENTURA
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
LISA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578062014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 PLUFF MUD ALY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-8149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-412-7033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 N HIGHWAY 17 UNIT J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-412-7033
Provider Business Practice Location Address Fax Number:
843-412-7033
Provider Enumeration Date:
02/11/2018

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: 225700000X , with the licence number:  5139 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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