Provider Demographics
NPI:1598483570
Name:DREAM CITY SPA LLC
Entity Type:Organization
Organization Name:DREAM CITY SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:704-579-4217
Mailing Address - Street 1:119 TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4878
Mailing Address - Country:US
Mailing Address - Phone:919-900-8919
Mailing Address - Fax:
Practice Address - Street 1:119 TIMBER DR
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4878
Practice Address - Country:US
Practice Address - Phone:919-900-8919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty