Provider Demographics
NPI:1124636212
Name:AG MASSAGE & BODYWORK LLC
Entity type:Organization
Organization Name:AG MASSAGE & BODYWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONSALVES
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, RCA
Authorized Official - Phone:407-720-8511
Mailing Address - Street 1:1317 EDGEWATER DR STE 1853
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6350
Mailing Address - Country:US
Mailing Address - Phone:407-720-8511
Mailing Address - Fax:407-612-2272
Practice Address - Street 1:1985 HOWELL BRANCH RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5901
Practice Address - Country:US
Practice Address - Phone:407-720-8511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty