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General NPI Number Information
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NPI Number | 1841534526
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Entity Type | Organization
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Legal Business Name | MASSAGE THERAPY CLINC
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Dates
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Enumeration Date | 11/19/2012
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Last Update Date | 11/19/2012
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Provider Practice Location Address
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Address Line | 6409 GEORGETOWN NORTH BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7007
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Country | US
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Telephone | 260-492-9999
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Fax | 260-969-1105
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Provider Business Mailing Address
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Address Line | 6409 GEORGETOWN NORTH BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-7007
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Country | US
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Telephone | 260-492-9999
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Fax | 260-492-1105
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Authorized Official
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Title or Position | CEO
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Name | MRS. KATHLEEN SUE JALAE-BROWN
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Credential |
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Telephone | 260-492-9999
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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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