Healthcare Provider Details

I. General information

NPI: 1154779155
Provider Name (Legal Business Name): DFW MEDICAL MASSAGE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SAINT MARY ST 300
ROCKWALL TX
75087-4017
US

IV. Provider business mailing address

105 SAINT MARY ST 300
ROCKWALL TX
75087-4017
US

V. Phone/Fax

Practice location:
  • Phone: 903-456-5712
  • Fax:
Mailing address:
  • Phone: 903-456-5712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DWIGHT LEE TINNEY
Title or Position: SOLE MEMBER
Credential: LMP, MMP, MFR, MAT
Phone: 903-456-5712