Provider Demographics
NPI:1669163093
Name:ELITE THERAPEUTIC MASSAGE CENTER, LLC
Entity type:Organization
Organization Name:ELITE THERAPEUTIC MASSAGE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MMT
Authorized Official - Phone:479-235-7150
Mailing Address - Street 1:2900 OLD GREENWOOD RD STE E
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4578
Mailing Address - Country:US
Mailing Address - Phone:479-235-7150
Mailing Address - Fax:
Practice Address - Street 1:2900 OLD GREENWOOD RD STE E
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4578
Practice Address - Country:US
Practice Address - Phone:479-235-7150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty