Provider Demographics
NPI:1306353214
Name:EQUILIBRIUM MASSAGE LLC
Entity type:Organization
Organization Name:EQUILIBRIUM MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMT
Authorized Official - Phone:214-310-0414
Mailing Address - Street 1:6320 LBJ FWY STE 122
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-6428
Mailing Address - Country:US
Mailing Address - Phone:214-310-0414
Mailing Address - Fax:
Practice Address - Street 1:6320 LBJ FWY STE 122
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6428
Practice Address - Country:US
Practice Address - Phone:214-310-0414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT116421225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty