1972807402 NPI number — BELLA LA VITA COMPANY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972807402 NPI number — BELLA LA VITA COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLA LA VITA COMPANY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JOURNEY MALIBU
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972807402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22516 CARBON MESA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALIBU
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90265-5019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-456-2551
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22516 CARBON MESA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALIBU
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90265-5019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-456-2551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOCKE
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CLAIMS ADMINISTRATOR
Authorized Official Telephone Number:
805-648-2570

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  190688AP , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)