Healthcare Provider Details

I. General information

NPI: 1760699466
Provider Name (Legal Business Name): MARIE ELENA BUMPASS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4319 MEDICAL DR STE 210A
SAN ANTONIO TX
78229-3381
US

IV. Provider business mailing address

7106 NORTHERN LIGHTS ST LOT 109-12
SAN ANTONIO TX
78238-1221
US

V. Phone/Fax

Practice location:
  • Phone: 210-615-0270
  • Fax: 210-615-0278
Mailing address:
  • Phone: 210-680-8285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT007570
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: