Healthcare Provider Details

I. General information

NPI: 1861720757
Provider Name (Legal Business Name): LA BONNA VITA COSMETIC SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 PAN AMERICAN FWY NE SUITE C
ALBUQUERQUE NM
87107-6831
US

IV. Provider business mailing address

4333 PAN AMERICAN FWY NE SUITE C
ALBUQUERQUE NM
87107-6831
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-6334
  • Fax:
Mailing address:
  • Phone: 505-344-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number89-270
License Number StateNM

VIII. Authorized Official

Name: JAMES LESTER
Title or Position: MANAGING MEMBER
Credential:
Phone: 505-453-7886