Provider Demographics
NPI:1336946011
Name:LAKE NORMAN MUAY THAI LLC
Entity type:Organization
Organization Name:LAKE NORMAN MUAY THAI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-502-7405
Mailing Address - Street 1:207 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8215
Mailing Address - Country:US
Mailing Address - Phone:704-657-1080
Mailing Address - Fax:
Practice Address - Street 1:107 COMMONS DR STE I
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9262
Practice Address - Country:US
Practice Address - Phone:704-657-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health