Provider Demographics
NPI:1215233697
Name:BELLA LUNA WOMAN CARE LLC
Entity type:Organization
Organization Name:BELLA LUNA WOMAN CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ASZANI
Authorized Official - Middle Name:STODDARD
Authorized Official - Last Name:KUNKLER
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, MSN
Authorized Official - Phone:612-356-4072
Mailing Address - Street 1:968 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3014
Mailing Address - Country:US
Mailing Address - Phone:651-895-2520
Mailing Address - Fax:651-330-3768
Practice Address - Street 1:968 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3014
Practice Address - Country:US
Practice Address - Phone:651-895-2520
Practice Address - Fax:651-330-3768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR192674-3261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service