Provider Demographics
NPI:1285869065
Name:BONNEVILLE DME
Entity type:Organization
Organization Name:BONNEVILLE DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-541-6137
Mailing Address - Street 1:4956 W 6200 S
Mailing Address - Street 2:# 254
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6703
Mailing Address - Country:US
Mailing Address - Phone:801-541-6137
Mailing Address - Fax:877-201-8904
Practice Address - Street 1:4956 W 6200 S
Practice Address - Street 2:# 254
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6703
Practice Address - Country:US
Practice Address - Phone:801-541-6137
Practice Address - Fax:877-201-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies