Provider Demographics
NPI:1093339269
Name:MYTHIC MASSAGE LLC
Entity Type:Organization
Organization Name:MYTHIC MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEWW
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMBT
Authorized Official - Phone:704-323-6718
Mailing Address - Street 1:5701 EXECUTIVE CENTER DR STE 350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8847
Mailing Address - Country:US
Mailing Address - Phone:704-323-6718
Mailing Address - Fax:
Practice Address - Street 1:5701 EXECUTIVE CENTER DR STE 350
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8847
Practice Address - Country:US
Practice Address - Phone:704-323-6718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain