Healthcare Provider Details

I. General information

NPI: 1801781331
Provider Name (Legal Business Name): THE KOKO BELLA PERMANENT MAKEUP AND LASH BAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 BALTIMORE REYNOLDSBURG RD
REYNOLDSBURG OH
43068-8105
US

IV. Provider business mailing address

257 KINGSMEADOW LN
BLACKLICK OH
43004-9204
US

V. Phone/Fax

Practice location:
  • Phone: 614-452-9821
  • Fax:
Mailing address:
  • Phone: 330-371-6698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: CARNEKA J GREEN
Title or Position: CERTIFIED PEER RECOVERY SUPPORTER
Credential:
Phone: 330-371-6698