Provider Demographics
NPI:1356105241
Name:AESTHETICS & BODY LAB
Entity type:Organization
Organization Name:AESTHETICS & BODY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:240-328-2015
Mailing Address - Street 1:9650 SANTIAGO RD STE 7
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3960
Mailing Address - Country:US
Mailing Address - Phone:301-309-7307
Mailing Address - Fax:301-238-8039
Practice Address - Street 1:9650 SANTIAGO RD STE 7
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3960
Practice Address - Country:US
Practice Address - Phone:301-309-7307
Practice Address - Fax:301-238-8039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty