Provider Demographics
NPI:1215105317
Name:BONIFACIO, R-PHINNE SUPENA (PT)
Entity type:Individual
Prefix:
First Name:R-PHINNE
Middle Name:SUPENA
Last Name:BONIFACIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 JAMAICA BLVD STE 21
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-3758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 JAMAICA BLVD PLAZA 1
Practice Address - Street 2:UNIT 21
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757-3758
Practice Address - Country:US
Practice Address - Phone:732-349-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00738700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ090489T09Medicare UPIN