Provider Demographics
NPI:1134977408
Name:BOMBSHELL AESTHETICS & WEIGHT LOSS CLINIC PLLC
Entity type:Organization
Organization Name:BOMBSHELL AESTHETICS & WEIGHT LOSS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:606-626-7093
Mailing Address - Street 1:197 OTTO DR # 42
Mailing Address - Street 2:
Mailing Address - City:INEZ
Mailing Address - State:KY
Mailing Address - Zip Code:41224-8808
Mailing Address - Country:US
Mailing Address - Phone:606-229-0072
Mailing Address - Fax:
Practice Address - Street 1:197 OTTO DR # 42
Practice Address - Street 2:
Practice Address - City:INEZ
Practice Address - State:KY
Practice Address - Zip Code:41224-8808
Practice Address - Country:US
Practice Address - Phone:606-229-0072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty