MEDICARE: BOUTIQUE BODYWORKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	682970000	TX

General Provider Information

NPI Number	:	1558876649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOUTIQUE BODYWORKS

Provider Business Mailing Address
First Line	:	9518 WAHADA AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5033
Country	:	US
Telephone Number	:	210-563-1070
Fax Number	:	210-876-1212

Provider Business Practice Location Address
First Line	:	9518 WAHADA AVE
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5033
Country	:	US
Telephone Number	:	210-563-1070
Fax Number	:	210-876-1212

Authorized Official
Title or Position	:	OWNER AND PRACTITIONER
Name	:	ALINA ACEBO KULCZYCKI
Credential	:	PT, DPT.
Telephone Number	:	210-563-1070

Provider Enumeration Date	:	12/11/2017
Last Update Date	:	01/11/2018

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