1437390598 NPI number — BACK IN SHAPE MASSAGE THERAPY

Table of content: (NPI 1437390598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437390598 NPI number — BACK IN SHAPE MASSAGE THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK IN SHAPE MASSAGE THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437390598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1539 DEVIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78130-7764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-516-5033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1528 E COMMON ST
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78130-3337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-516-5033
Provider Business Practice Location Address Fax Number:
830-837-5137
Provider Enumeration Date:
03/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
ATWELL
Authorized Official First Name:
ANNETTA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
PARTNER/MASSAGE THERAPIST
Authorized Official Telephone Number:
210-516-5033

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MT 049022 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 613532800 . This is a "OWCP/FECA/WORKMAN'S COMP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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