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General NPI Number Information
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NPI Number | 1336527449
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Entity Type | Organization
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Legal Business Name | EGATE, LLC
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Dates
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Enumeration Date | 05/08/2015
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Last Update Date | 05/08/2015
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Provider Practice Location Address
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Address Line | 12818 CENTURY DR STE 1102
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City | STAFFORD
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State | TX
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Zip | 77477-4224
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Country | US
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Telephone | 832-741-7654
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Fax |
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Provider Business Mailing Address
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Address Line | 12307 MAPLE LEAF LN
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City | STAFFORD
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State | TX
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Zip | 77477-1691
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Country | US
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Telephone | 832-741-7654
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | MR. JASON WONG
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Credential | LMT
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Telephone | 832-741-7654
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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 | MT119442
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License Number State | TX
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