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General NPI Number Information
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NPI Number | 1730463852
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Entity Type | Organization
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Legal Business Name | GLENDALE SPORTS MASSAGE LLC
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Dates
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Enumeration Date | 10/07/2011
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Last Update Date | 11/30/2011
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Provider Practice Location Address
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Address Line | 6808 N DYSART RD #136
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City | GLENDALE
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State | AZ
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Zip | 85307-2231
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Country | US
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Telephone | 623-215-2525
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Fax |
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Provider Business Mailing Address
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Address Line | 6808 N DYSART RD #136
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City | GLENDALE
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State | AZ
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Zip | 85307-2231
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Country | US
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Telephone | 623-215-2525
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. EAGLE BOWERS
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Credential | BA, CFT,LMT
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Telephone | 623-215-2525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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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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