Basic Information
| Provider Information | |||||||||
| NPI: | 1528573995 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLEZA MED SPA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4421 IRVING BLVD NW STE C | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871145919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058974433 | ||||||||
| FaxNumber: | 5058973085 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053449478 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | PACHECO | ||||||||
| AuthorizedOfficialFirstName: | EVA | ||||||||
| AuthorizedOfficialMiddleName: | CRISTINA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5058974433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.