Healthcare Provider Details

I. General information

NPI: 1790500338
Provider Name (Legal Business Name): BEA CLAM MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 E ALTON GLOOR BLVD STE B
BROWNSVILLE TX
78526-3919
US

IV. Provider business mailing address

1273 E ALTON GLOOR BLVD STE B
BROWNSVILLE TX
78526-3919
US

V. Phone/Fax

Practice location:
  • Phone: 956-674-3885
  • Fax: 956-621-0794
Mailing address:
  • Phone: 956-674-3885
  • Fax: 956-621-0794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: BENYTHA GONZALEZ
Title or Position: OWNER
Credential:
Phone: 956-832-4953