Healthcare Provider Details

I. General information

NPI: 1932750056
Provider Name (Legal Business Name): CENTER FOR MYOFASCIAL THERAPEUTICS AND AESTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9430 WICKER AVE
SAINT JOHN IN
46373-9400
US

IV. Provider business mailing address

9430 WICKER AVE
SAINT JOHN IN
46373-9400
US

V. Phone/Fax

Practice location:
  • Phone: 219-558-8068
  • Fax: 877-822-9116
Mailing address:
  • Phone: 219-558-8068
  • Fax: 877-822-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ARIEL BRAZZALE
Title or Position: CEO
Credential: NP
Phone: 219-669-1034