Provider Demographics
NPI:1073982070
Name:BELLIS
Entity Type:Organization
Organization Name:BELLIS
Other - Org Name:BELLIS THERAPEUTIC SPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MT, ESTHETICIAN
Authorized Official - Phone:248-442-0034
Mailing Address - Street 1:33037 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3119
Mailing Address - Country:US
Mailing Address - Phone:248-442-0034
Mailing Address - Fax:
Practice Address - Street 1:33037 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3119
Practice Address - Country:US
Practice Address - Phone:248-442-0034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-20
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005119305S00000X
MI2705003188305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service