Provider Demographics
NPI:1346567450
Name:THERAPEUTIC MASSAGE OF SOUTHWEST FLORIDA, INC.
Entity Type:Organization
Organization Name:THERAPEUTIC MASSAGE OF SOUTHWEST FLORIDA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLIDDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:239-994-6558
Mailing Address - Street 1:3315 SW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5112
Mailing Address - Country:US
Mailing Address - Phone:239-994-6558
Mailing Address - Fax:239-481-0022
Practice Address - Street 1:6700 WINKLER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7233
Practice Address - Country:US
Practice Address - Phone:239-994-6558
Practice Address - Fax:239-481-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA58593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty