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General NPI Number Information
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NPI Number | 1376131896
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Entity Type | Organization
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Legal Business Name | CRYSTAL OWL MASSAGE
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Dates
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Enumeration Date | 01/10/2021
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Last Update Date | 01/10/2021
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Provider Practice Location Address
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Address Line | 6900 TAVISTOCK LAKES BLVD STE 110
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City | ORLANDO
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State | FL
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Zip | 32827-7590
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Country | US
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Telephone | 407-906-6550
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Fax |
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Provider Business Mailing Address
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Address Line | 1146 DELPHINIUM DR
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City | ORLANDO
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State | FL
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Zip | 32825-6712
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Country | US
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Telephone | 407-929-2325
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CALVIN NGO
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Credential |
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Telephone | 407-929-2325
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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 |
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License Number State |
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