Healthcare Provider Details

I. General information

NPI: 1619366838
Provider Name (Legal Business Name): MASSAGE WORKS THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804
US

IV. Provider business mailing address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-1111
  • Fax: 260-459-2209
Mailing address:
  • Phone: 260-459-1111
  • Fax: 260-459-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT21003391
License Number StateIN

VIII. Authorized Official

Name: MICHAEL WINDSOR JR.
Title or Position: OWNER
Credential: CMT
Phone: 260-459-1111