1558613489 NPI number — BELLA FAMILY HEALTH AND WELLNESS, LLC

Table of content: JONATHAN ROSS BEARD LSW (NPI 1528699709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558613489 NPI number — BELLA FAMILY HEALTH AND WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLA FAMILY HEALTH AND WELLNESS, LLC
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:
Provider Other Organization Name Type Code:
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:
1558613489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2502 GALEN DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61821-7045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-355-8346
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 DEERPATH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61920-9427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-345-4325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WENZEL
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
217-355-8346

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  248.000561 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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