Provider Demographics
NPI:1700195393
Name:FAST TWITCH ATHLETIC WELLNESS, LLC
Entity Type:Organization
Organization Name:FAST TWITCH ATHLETIC WELLNESS, LLC
Other - Org Name:FAST TWITCH ATHLETIC TRAINING & PERSONAL WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FOUNDER/GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-865-2236
Mailing Address - Street 1:24022 CINCO VILLAGE CENTER BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-8397
Mailing Address - Country:US
Mailing Address - Phone:281-391-3648
Mailing Address - Fax:
Practice Address - Street 1:24022 CINCO VILLAGE CENTER BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-8397
Practice Address - Country:US
Practice Address - Phone:281-391-3648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11706682251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty