Provider Demographics
NPI:1154815439
Name:FIRE & ICE THERAPEUTIC MASSAGE,LLC
Entity Type:Organization
Organization Name:FIRE & ICE THERAPEUTIC MASSAGE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:LMBT
Authorized Official - Phone:704-763-2059
Mailing Address - Street 1:4732 LEBANON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9112
Mailing Address - Country:US
Mailing Address - Phone:704-763-2059
Mailing Address - Fax:980-317-8495
Practice Address - Street 1:4732 LEBANON RD
Practice Address - Street 2:SUITE A
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9112
Practice Address - Country:US
Practice Address - Phone:704-763-2059
Practice Address - Fax:980-317-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14844225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty