Provider Demographics
NPI:1003135815
Name:MEDICAL MASSAGE THERAPY
Entity Type:Organization
Organization Name:MEDICAL MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AKACHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:409-201-1964
Mailing Address - Street 1:PO BOX 1376
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77641-1376
Mailing Address - Country:US
Mailing Address - Phone:409-201-1964
Mailing Address - Fax:409-982-9090
Practice Address - Street 1:3100 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2734
Practice Address - Country:US
Practice Address - Phone:409-201-1964
Practice Address - Fax:409-982-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109921111NR0400X, 283X00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
No283X00000XHospitalsRehabilitation Hospital
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty