Provider Demographics
NPI:1396202776
Name:BASE MEDICAL SPA
Entity Type:Organization
Organization Name:BASE MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:219-644-6716
Mailing Address - Street 1:442 N CALUMET RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2489
Mailing Address - Country:US
Mailing Address - Phone:219-644-6716
Mailing Address - Fax:
Practice Address - Street 1:442 N CALUMET RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2489
Practice Address - Country:US
Practice Address - Phone:219-644-6716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BASE SPA & WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty