Provider Demographics
NPI:1922279041
Name:THAI MEDICAL MASSAGE
Entity Type:Organization
Organization Name:THAI MEDICAL MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:POUNGSRI
Authorized Official - Middle Name:
Authorized Official - Last Name:VONBERNUTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:813-685-2315
Mailing Address - Street 1:110 E WINDHORST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 E WINDHORST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-2524
Practice Address - Country:US
Practice Address - Phone:813-685-2315
Practice Address - Fax:813-685-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA13798225700000X
FLMM11331261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty