Provider Demographics
NPI:1417578816
Name:DESTINO BELLA, LLC.
Entity Type:Organization
Organization Name:DESTINO BELLA, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANAI
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-222-4355
Mailing Address - Street 1:755 S TELSHOR BLVD STE S102
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4688
Mailing Address - Country:US
Mailing Address - Phone:575-222-4355
Mailing Address - Fax:575-800-0344
Practice Address - Street 1:755 S TELSHOR BLVD STE S102
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4688
Practice Address - Country:US
Practice Address - Phone:575-222-4355
Practice Address - Fax:575-800-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28909585Medicaid
NM413154YRNDOtherMEDICARE