Healthcare Provider Details

I. General information

NPI: 1013372648
Provider Name (Legal Business Name): LA DE DA BODY SPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2015
Last Update Date: 12/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 E ROBINSON ST
ORLANDO FL
32803-6045
US

IV. Provider business mailing address

2022 E ROBINSON ST
ORLANDO FL
32803-6045
US

V. Phone/Fax

Practice location:
  • Phone: 407-900-5937
  • Fax:
Mailing address:
  • Phone: 407-900-5937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA78414
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberMA78414
License Number StateFL

VIII. Authorized Official

Name: MRS. HEATHER LYNN CEGIELSKI
Title or Position: OWNER/MASSAGE THERAPIST
Credential: LMT,MMP
Phone: 407-900-5937