Provider Demographics
NPI:1861720757
Name:LA BONNA VITA COSMETIC SPA, LLC
Entity type:Organization
Organization Name:LA BONNA VITA COSMETIC SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-453-7886
Mailing Address - Street 1:4333 PAN AMERICAN FWY NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6831
Mailing Address - Country:US
Mailing Address - Phone:505-344-6334
Mailing Address - Fax:
Practice Address - Street 1:4333 PAN AMERICAN FWY NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-6831
Practice Address - Country:US
Practice Address - Phone:505-344-6334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-270207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty