Provider Demographics
NPI:1962036228
Name:NEW LIFE MYOFASCIAL RELEASE, LLC
Entity type:Organization
Organization Name:NEW LIFE MYOFASCIAL RELEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:941-773-7620
Mailing Address - Street 1:2101 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1047
Mailing Address - Country:US
Mailing Address - Phone:813-461-4171
Mailing Address - Fax:
Practice Address - Street 1:2101 W STATE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-1047
Practice Address - Country:US
Practice Address - Phone:813-461-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1477855211Medicaid