Provider Demographics
NPI:1063930667
Name:BODY RESTORATION AND RELAXATION MASSAGE THERAPY, LLC
Entity type:Organization
Organization Name:BODY RESTORATION AND RELAXATION MASSAGE THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:AUL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:512-937-2979
Mailing Address - Street 1:100 E WHITESTONE BLVD STE 148 # 177
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6937
Mailing Address - Country:US
Mailing Address - Phone:512-937-2979
Mailing Address - Fax:
Practice Address - Street 1:1335 E WHITESTONE BLVD BLDG O SUITE 9
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:512-937-2979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-03
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT125571225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty