Healthcare Provider Details

I. General information

NPI: 1336555853
Provider Name (Legal Business Name): LA BELLA SPA SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10126 COORS BLVD NW
ALBUQUERQUE NM
87114-4022
US

IV. Provider business mailing address

9687 ASBURY LN NW
ALBUQUERQUE NM
87114-4344
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-5557
  • Fax:
Mailing address:
  • Phone: 505-206-2378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberLMT2169
License Number StateNM

VIII. Authorized Official

Name: DAWN DAVIDE
Title or Position: OWNNER
Credential:
Phone: 505-899-5557