Provider Demographics
NPI:1740518513
Name:TUCSON MYOFASCIAL RELEASE & MASSAGE LLC
Entity type:Organization
Organization Name:TUCSON MYOFASCIAL RELEASE & MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:520-971-4866
Mailing Address - Street 1:7739 E BROADWAY BLVD
Mailing Address - Street 2:83
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3941
Mailing Address - Country:US
Mailing Address - Phone:520-971-4866
Mailing Address - Fax:520-733-0406
Practice Address - Street 1:850 N KOLB RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-1333
Practice Address - Country:US
Practice Address - Phone:520-971-4866
Practice Address - Fax:520-733-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-06
Last Update Date:2009-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-12870225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty