Healthcare Provider Details

I. General information

NPI: 1821625815
Provider Name (Legal Business Name): ESSENTIAL BODY BAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 W ALABAMA ST
HOUSTON TX
77006-4102
US

IV. Provider business mailing address

1622 W ALABAMA ST
HOUSTON TX
77006-4102
US

V. Phone/Fax

Practice location:
  • Phone: 832-808-0903
  • Fax: 832-553-7762
Mailing address:
  • Phone: 832-808-0903
  • Fax: 832-553-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LETRICE KAY MASON
Title or Position: NURSE PRACTITIONER/OWNER
Credential: NP
Phone: 817-874-5505