Healthcare Provider Details

I. General information

NPI: 1801715487
Provider Name (Legal Business Name): BL MED SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 W OLIVE AVE STE 118F-6
GLENDALE AZ
85302-3843
US

IV. Provider business mailing address

5301 E WONDERVIEW RD
PHOENIX AZ
85018-1940
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-4626
  • Fax:
Mailing address:
  • Phone: 602-888-4626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SARA AHDOOT
Title or Position: OWNER
Credential:
Phone: 480-406-5281