Basic Information
| Provider Information | |||||||||
| NPI: | 1437472925 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BACKSTRETCH SOUTH FLORIDA | ||||||||
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| OtherOrganizationName: | ELEMENTS THERAPEUTIC MASSAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6290 W SAMPLE RD | ||||||||
| Address2: | #102 | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330673101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547572939 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6290 W SAMPLE RD | ||||||||
| Address2: | #102 | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330673101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547572939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | CASPER | ||||||||
| AuthorizedOfficialFirstName: | LOUISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5616766545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MM21953 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.