Provider Demographics
NPI:1861000317
Name:BELLA AESTHETICA, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BELLA AESTHETICA, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-712-4811
Mailing Address - Street 1:625 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3223
Mailing Address - Country:US
Mailing Address - Phone:909-984-7500
Mailing Address - Fax:909-984-7550
Practice Address - Street 1:625 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3223
Practice Address - Country:US
Practice Address - Phone:909-984-7500
Practice Address - Fax:909-984-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB315364OtherMEDICARE