Provider Demographics
NPI:1376131896
Name:CRYSTAL OWL MASSAGE
Entity Type:Organization
Organization Name:CRYSTAL OWL MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-929-2325
Mailing Address - Street 1:1146 DELPHINIUM DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6712
Mailing Address - Country:US
Mailing Address - Phone:407-929-2325
Mailing Address - Fax:
Practice Address - Street 1:6900 TAVISTOCK LAKES BLVD STE 110
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7590
Practice Address - Country:US
Practice Address - Phone:407-906-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty