Provider Demographics
NPI:1780371989
Name:SPA LOUNGE LLC
Entity type:Organization
Organization Name:SPA LOUNGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MERCY
Authorized Official - Last Name:DIMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-771-7277
Mailing Address - Street 1:3355 CHERRY RIDGE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4818
Mailing Address - Country:US
Mailing Address - Phone:210-772-7177
Mailing Address - Fax:
Practice Address - Street 1:3355 CHERRY RIDGE DR STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4818
Practice Address - Country:US
Practice Address - Phone:210-772-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty