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General NPI Number Information
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NPI Number | 1336946011
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Entity Type | Organization
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Legal Business Name | LAKE NORMAN MUAY THAI LLC
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Dates
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Enumeration Date | 02/28/2025
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 107 COMMONS DR STE I
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City | MOORESVILLE
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State | NC
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Zip | 28117-9262
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Country | US
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Telephone | 704-657-1080
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Fax |
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Provider Business Mailing Address
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Address Line | 207 HICKORY HILL RD
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City | MOORESVILLE
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State | NC
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Zip | 28117-8215
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Country | US
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Telephone | 704-657-1080
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Fax |
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Authorized Official
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Title or Position | ACCOUNTANT
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Name | JENNIFER W SMITH
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Credential |
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Telephone | 704-502-7405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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