Provider Demographics
NPI:1437390598
Name:BACK IN SHAPE MASSAGE THERAPY
Entity Type:Organization
Organization Name:BACK IN SHAPE MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ATWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:210-516-5033
Mailing Address - Street 1:1539 DEVIN DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-7764
Mailing Address - Country:US
Mailing Address - Phone:210-516-5033
Mailing Address - Fax:
Practice Address - Street 1:1528 E COMMON ST
Practice Address - Street 2:SUITE 18
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3337
Practice Address - Country:US
Practice Address - Phone:210-516-5033
Practice Address - Fax:830-837-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT 049022225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613532800OtherOWCP/FECA/WORKMAN'S COMP