Provider Demographics
NPI:1629178082
Name:ANGIE'S SPA, LLC
Entity Type:Organization
Organization Name:ANGIE'S SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUGEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-547-6458
Mailing Address - Street 1:26700 BROOKPARK ROAD EXT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3124
Mailing Address - Country:US
Mailing Address - Phone:440-716-1283
Mailing Address - Fax:440-716-1605
Practice Address - Street 1:715 S TAFT AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3200
Practice Address - Country:US
Practice Address - Phone:419-333-2710
Practice Address - Fax:419-333-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOSS021129332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2471463Medicaid
OH=========001OtherTRICARE
=========003OtherMEDICAL MUTUAL OF OHIO
OH2471463Medicaid
=========003OtherMEDICAL MUTUAL OF OHIO