Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 22784 | CA |
NPI | 1003578006 |
---|---|
Provider Name | Edward Xavier Bonilla |
First Address | Murrieta, CA 92562-6177 |
Second Address | Hemet, CA 92545-9697 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2021 |
Last Update Date | 07/10/2021 |