Provider Demographics
NPI:1093969792
Name:MASSAGE SPACE, CO.
Entity Type:Organization
Organization Name:MASSAGE SPACE, CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:V
Authorized Official - Last Name:KOLMAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-612-5363
Mailing Address - Street 1:4152 W SPRING CREEK PKWY STE 116
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-5315
Mailing Address - Country:US
Mailing Address - Phone:972-612-5363
Mailing Address - Fax:972-612-5782
Practice Address - Street 1:4152 W SPRING CREEK PKWY STE 116
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-5315
Practice Address - Country:US
Practice Address - Phone:972-612-5363
Practice Address - Fax:972-612-5782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization