1518153295 NPI number — SANDRA EUGENIA WALLACE MASSAGE THERAPIST

Table of content: SANDRA EUGENIA WALLACE MASSAGE THERAPIST (NPI 1518153295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518153295 NPI number — SANDRA EUGENIA WALLACE MASSAGE THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
SANDRA
Provider Middle Name:
EUGENIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASSAGE THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLACE
Provider Other First Name:
SANDRA
Provider Other Middle Name:
EUGENIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ASSOCIATES DEGREE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518153295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3627 ACORNRUN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77389-4721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-651-7716
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 ACORNRUN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77389-4721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-651-7716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  016400 , 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)





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