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General NPI Number Information
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NPI Number | 1356105241
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Entity Type | Organization
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Legal Business Name | AESTHETICS & BODY LAB
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 9650 SANTIAGO RD STE 7
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City | COLUMBIA
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State | MD
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Zip | 21045-3960
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Country | US
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Telephone | 301-309-7307
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Fax | 301-238-8039
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Provider Business Mailing Address
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Address Line | 9650 SANTIAGO RD STE 7
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City | COLUMBIA
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State | MD
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Zip | 21045-3960
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Country | US
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Telephone | 301-309-7307
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Fax | 301-238-8039
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Authorized Official
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Title or Position | OWNER
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Name | KEISHA BERNARD
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Credential | NP
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Telephone | 240-328-2015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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