Provider Demographics
NPI:1942577960
Name:BELLA'S RESERVE
Entity Type:Organization
Organization Name:BELLA'S RESERVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-622-0400
Mailing Address - Street 1:2120 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1998
Mailing Address - Country:US
Mailing Address - Phone:301-622-0400
Mailing Address - Fax:301-622-4383
Practice Address - Street 1:2120 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1998
Practice Address - Country:US
Practice Address - Phone:301-622-0400
Practice Address - Fax:301-622-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420736000Medicaid