Provider Demographics
NPI:1649883349
Name:ANDAMAN SPA SPORT MEDICINE
Entity type:Organization
Organization Name:ANDAMAN SPA SPORT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-744-6688
Mailing Address - Street 1:2050 NORTH LOOP W STE 116
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-8111
Mailing Address - Country:US
Mailing Address - Phone:832-744-6688
Mailing Address - Fax:
Practice Address - Street 1:2050 NORTH LOOP W STE 116
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8111
Practice Address - Country:US
Practice Address - Phone:832-744-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty