Provider Demographics
NPI:1326482076
Name:CORPO BELLO FULL SERVICE DAY SPA
Entity Type:Organization
Organization Name:CORPO BELLO FULL SERVICE DAY SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOHANNAN-BIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-3400
Mailing Address - Street 1:1703 W CANDLETREE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1591
Mailing Address - Country:US
Mailing Address - Phone:309-692-3400
Mailing Address - Fax:
Practice Address - Street 1:1703 W CANDLETREE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1591
Practice Address - Country:US
Practice Address - Phone:309-692-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011.259084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty