Provider Demographics
NPI:1932750056
Name:CENTER FOR MYOFASCIAL THERAPEUTICS AND AESTHETICS
Entity Type:Organization
Organization Name:CENTER FOR MYOFASCIAL THERAPEUTICS AND AESTHETICS
Other - Org Name:BRAZZALE SURGICAL ASSISTING LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAZZALE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:219-669-1034
Mailing Address - Street 1:9430 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9400
Mailing Address - Country:US
Mailing Address - Phone:219-558-8068
Mailing Address - Fax:877-822-9116
Practice Address - Street 1:9430 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9400
Practice Address - Country:US
Practice Address - Phone:219-558-8068
Practice Address - Fax:877-822-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71013263AOtherINDIANA NURSING BOARD LICENSE