Provider Demographics
NPI:1780604264
Name:TSOBNANG, BONIFACE
Entity type:Individual
Prefix:MR
First Name:BONIFACE
Middle Name:
Last Name:TSOBNANG
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 1:10125 PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-3800
Mailing Address - Country:US
Mailing Address - Phone:310-204-3425
Mailing Address - Fax:
Practice Address - Street 1:3700 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1010
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2901
Practice Address - Country:US
Practice Address - Phone:213-365-9612
Practice Address - Fax:213-365-9441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43109332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies