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General NPI Number Information
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NPI Number | 1922867720
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Entity Type | Organization
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Legal Business Name | TRACE BODY REJUVENATION, SPORTS RECOVERY, PAIN RELIEF, AND AESTHETICS
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Dates
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Enumeration Date | 03/15/2024
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Last Update Date | 03/15/2024
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Provider Practice Location Address
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Address Line | 829 FROSTWOOD DR
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City | HOUSTON
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State | TX
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Zip | 77024-4131
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Country | US
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Telephone | 281-571-3209
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Fax |
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Provider Business Mailing Address
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Address Line | 829 FROSTWOOD DR
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City | HOUSTON
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State | TX
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Zip | 77024-4131
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Country | US
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Telephone | 281-571-3209
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Fax |
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Authorized Official
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Title or Position | CO-FOUNDER
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Name | ANDREW RAYMOND KALUZA
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Credential |
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Telephone | 254-495-5048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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