Provider Demographics
NPI:1518782481
Name:THE OBSIDIAN SPA LLC
Entity type:Organization
Organization Name:THE OBSIDIAN SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEFERTITI
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-533-8775
Mailing Address - Street 1:8704 RED RIO DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8436
Mailing Address - Country:US
Mailing Address - Phone:916-533-8775
Mailing Address - Fax:
Practice Address - Street 1:5770 S DURANGO DR
Practice Address - Street 2:SUITE 110, STUDIO 20
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113
Practice Address - Country:US
Practice Address - Phone:702-551-9045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty