MEDICARE: ANDAMAN SPA SPORT MEDICINE

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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1649883349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDAMAN SPA SPORT MEDICINE

Provider Business Mailing Address
First Line	:	2050 NORTH LOOP W STE 116
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-8111
Country	:	US
Telephone Number	:	832-744-6688
Fax Number	:

Provider Business Practice Location Address
First Line	:	2050 NORTH LOOP W STE 116
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-8111
Country	:	US
Telephone Number	:	832-744-6688
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACKELINE CARDONA
Credential	:
Telephone Number	:	832-744-6688

Provider Enumeration Date	:	08/24/2020
Last Update Date	:	08/24/2020

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Directions to “ANDAMAN SPA SPORT MEDICINE ” Practice Location

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