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General NPI Number Information
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NPI Number | 1700195393
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Entity Type | Organization
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Legal Business Name | FAST TWITCH ATHLETIC WELLNESS, LLC
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 09/29/2010
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Provider Practice Location Address
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Address Line | 24022 CINCO VILLAGE CENTER BLVD SUITE 120
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City | KATY
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State | TX
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Zip | 77494-8397
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Country | US
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Telephone | 281-391-3648
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Fax |
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Provider Business Mailing Address
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Address Line | 24022 CINCO VILLAGE CENTER BLVD SUITE 120
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City | KATY
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State | TX
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Zip | 77494-8397
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Country | US
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Telephone | 281-391-3648
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Fax |
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Authorized Official
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Title or Position | FOUNDER/GENERAL MANAGER
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Name | MR. DEMOND C. JORDAN
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Credential |
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Telephone | 281-865-2236
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 1170668
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License Number State | TX
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