Provider Demographics
NPI:1366952277
Name:MBONIFOR, ELIAS CHE
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:CHE
Last Name:MBONIFOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S EASTERN ST APT 201
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-2462
Mailing Address - Country:US
Mailing Address - Phone:310-651-0772
Mailing Address - Fax:
Practice Address - Street 1:624 S EASTERN ST APT 201
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-2462
Practice Address - Country:US
Practice Address - Phone:310-651-0772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8723655172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver