Basic Information
| Provider Information | |||||||||
| NPI: | 1245337906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONILLA | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9873 BAYWINDS DR | ||||||||
| Address2: | UNIT 5211 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334111845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619060607 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3898 VIA POINCIANA | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619669273 | ||||||||
| FaxNumber: | 5619668810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 22295 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.