Provider Demographics
NPI:1295058782
Name:ADVANCE THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:ADVANCE THERAPEUTIC MASSAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:NCTMB, LMT
Authorized Official - Phone:864-653-4177
Mailing Address - Street 1:402 PENDLETON RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631
Mailing Address - Country:US
Mailing Address - Phone:864-653-4177
Mailing Address - Fax:
Practice Address - Street 1:402 PENDLETON RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2242
Practice Address - Country:US
Practice Address - Phone:864-653-4177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4650172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty