Provider Demographics
NPI:1588775647
Name:BONAVENTURE MEDICAL FOUNDATION, LLC
Entity type:Organization
Organization Name:BONAVENTURE MEDICAL FOUNDATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:REINHOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:LLERENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-692-6482
Mailing Address - Street 1:2380 E DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-4839
Mailing Address - Country:US
Mailing Address - Phone:855-692-6482
Mailing Address - Fax:
Practice Address - Street 1:2380 E DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4839
Practice Address - Country:US
Practice Address - Phone:855-692-6482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BONAVENTURE MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty