=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063045565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA BELLA MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2020
-----------------------------------------------------
Last Update Date | 02/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 OAKHEART RD
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-1252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-424-3015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 48TH AVE N
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29577-5417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUMMER MUELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 800-294-7001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------