Provider Demographics
NPI:1528149069
Name:SMITH, BRENDA BONILLA (LAC)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:BONILLA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:99 S CHESTER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-5805
Mailing Address - Country:US
Mailing Address - Phone:626-356-3220
Mailing Address - Fax:626-356-3222
Practice Address - Street 1:99 S CHESTER AVE STE 101
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-5805
Practice Address - Country:US
Practice Address - Phone:626-356-3220
Practice Address - Fax:626-356-3222
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7809171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist