Provider Information for 1730628363
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BONAVY SOM-KEO
Sex: Female
NPI: 1730628363
Last Updated: 2024-07-24
Certification Date: 2024-07-24
Certification Date: 2024-07-24
Details
Name | Value | ||||||||||||||||
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NPI | 1730628363 | ||||||||||||||||
Enumeration Date | 2017-02-15 | ||||||||||||||||
NPI Type | NPI-1 Individual | ||||||||||||||||
Sole Proprietor | YES | ||||||||||||||||
Status | Active | ||||||||||||||||
Mailing Address | 14112 S KINGSLEY DR GARDENA, CA 90249-3018 United States Phone: 310-217-7312 | Fax: | ||||||||||||||||
Primary Practice Address | 14112 S KINGSLEY DR GARDENA, CA 90249-3018 United States Phone: 310-217-7312 | Fax: | ||||||||||||||||
Secondary Practice Address(es) | 18350 MOUNT LANGLEY ST | ||||||||||||||||
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