Provider Demographics
NPI:1407365141
Name:MELTON, JOHNATHON
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:
Last Name:MELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S LAKELINE BLVD APT 436
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3915
Mailing Address - Country:US
Mailing Address - Phone:830-305-0735
Mailing Address - Fax:
Practice Address - Street 1:14028 N HWY 183 STE D120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-5992
Practice Address - Country:US
Practice Address - Phone:512-250-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT111929OtherMASSAGE THERAPY