Basic Information
| Provider Information | |||||||||
| NPI: | 1952604977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONNEY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 30141 ANTELOPE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925847001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517231866 | ||||||||
| FaxNumber: | 9517231867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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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 | PT37413 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0PT374130 | 01 | CA | BLUE SHIELD OF CALIFORNIA | OTHER |