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General NPI Number Information
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NPI Number | 1114171543
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Entity Type | Organization
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Legal Business Name | QUINTESSENTIAL CREATIONS
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Dates
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Enumeration Date | 11/12/2008
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Last Update Date | 11/12/2008
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Provider Practice Location Address
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Address Line | 111 S WILSON ST
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City | BURLESON
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State | TX
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Zip | 76028-4239
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Country | US
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Telephone | 817-295-7444
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Fax |
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Provider Business Mailing Address
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Address Line | 109 E WALNUT ST
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City | KEENE
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State | TX
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Zip | 76059-2329
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Country | US
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Telephone | 817-645-6590
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Fax | 817-231-0333
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Authorized Official
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Title or Position | MASSAGE THERAPIST
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Name | MR. JAMES LEROY SCHLOUGH
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Credential | CMT
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Telephone | 817-774-1039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT105553
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License Number State | TX
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