Provider Demographics
NPI:1558323097
Name:ANGIE'S SPA LLC
Entity type:Organization
Organization Name:ANGIE'S SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUGEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-483-3793
Mailing Address - Street 1:855 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-9078
Mailing Address - Country:US
Mailing Address - Phone:419-483-3793
Mailing Address - Fax:419-483-5417
Practice Address - Street 1:855 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9078
Practice Address - Country:US
Practice Address - Phone:419-483-3793
Practice Address - Fax:419-483-5417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2471463Medicaid
OH000000340887OtherANTHEM
OH=========001OtherTRICARE
OH=========002OtherMEDICAL MUTUAL OF OHIO
OH2471463Medicaid
OH=========00OtherWORKERS COMP