Provider Demographics
NPI:1922867720
Name:TRACE BODY REJUVENATION, SPORTS RECOVERY, PAIN RELIEF, AND AESTHETICS
Entity Type:Organization
Organization Name:TRACE BODY REJUVENATION, SPORTS RECOVERY, PAIN RELIEF, AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KALUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-495-5048
Mailing Address - Street 1:829 FROSTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-4131
Mailing Address - Country:US
Mailing Address - Phone:281-571-3209
Mailing Address - Fax:
Practice Address - Street 1:829 FROSTWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-4131
Practice Address - Country:US
Practice Address - Phone:281-571-3209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center