Provider Demographics
NPI:1073865234
Name:MASSAGE THERAPY CENTERS OF AMERICA, INC
Entity Type:Organization
Organization Name:MASSAGE THERAPY CENTERS OF AMERICA, INC
Other - Org Name:RIVER NORTH MASSAGE THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BISTAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MBA
Authorized Official - Phone:312-854-2834
Mailing Address - Street 1:747 NORTH LASALLE DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:312-854-2834
Mailing Address - Fax:
Practice Address - Street 1:747 NORTH LASALLE DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-854-2834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty