Provider Demographics
NPI:1790134401
Name:ADVANCED MEDICAL MASSAGE
Entity Type:Organization
Organization Name:ADVANCED MEDICAL MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:214-288-1941
Mailing Address - Street 1:4601 OLD SHEPARD PL
Mailing Address - Street 2:BUILDING #4 SUITE 404
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5279
Mailing Address - Country:US
Mailing Address - Phone:214-288-1941
Mailing Address - Fax:
Practice Address - Street 1:4601 OLD SHEPARD PL
Practice Address - Street 2:BUILDING #4 SUITE 404
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5279
Practice Address - Country:US
Practice Address - Phone:214-288-1941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT103513225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty