Provider Demographics
NPI:1255612933
Name:BELLA MEDICA LASER CENTER
Entity type:Organization
Organization Name:BELLA MEDICA LASER CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR. OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:RADER
Authorized Official - Suffix:
Authorized Official - Credentials:CLT
Authorized Official - Phone:815-344-0303
Mailing Address - Street 1:5435 BULL VALLEY RD
Mailing Address - Street 2:SUITE#118
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-7434
Mailing Address - Country:US
Mailing Address - Phone:815-344-0303
Mailing Address - Fax:
Practice Address - Street 1:5435 BULL VALLEY RD
Practice Address - Street 2:SUITE#118
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-7434
Practice Address - Country:US
Practice Address - Phone:815-344-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILNA246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty