Provider Demographics
NPI:1730463852
Name:GLENDALE SPORTS MASSAGE LLC
Entity Type:Organization
Organization Name:GLENDALE SPORTS MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EAGLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CFT,LMT
Authorized Official - Phone:623-215-2525
Mailing Address - Street 1:6808 N DYSART RD
Mailing Address - Street 2:#136
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-2231
Mailing Address - Country:US
Mailing Address - Phone:623-215-2525
Mailing Address - Fax:
Practice Address - Street 1:6808 N DYSART RD
Practice Address - Street 2:#136
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-2231
Practice Address - Country:US
Practice Address - Phone:623-215-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-07
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty