Provider Demographics
NPI:1013372648
Name:LA DE DA BODY SPA, LLC
Entity Type:Organization
Organization Name:LA DE DA BODY SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CEGIELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LMT,MMP
Authorized Official - Phone:407-900-5937
Mailing Address - Street 1:2022 E ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-6045
Mailing Address - Country:US
Mailing Address - Phone:407-900-5937
Mailing Address - Fax:
Practice Address - Street 1:2022 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6045
Practice Address - Country:US
Practice Address - Phone:407-900-5937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-26
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA78414225700000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA78414OtherLMT # MA78414