Provider Demographics
NPI:1174701353
Name:THE GREAT ESCAPE
Entity type:Organization
Organization Name:THE GREAT ESCAPE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MLT
Authorized Official - Phone:940-736-3156
Mailing Address - Street 1:1500 E HIGHWAY 82
Mailing Address - Street 2:SUITE -26
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2831
Mailing Address - Country:US
Mailing Address - Phone:940-736-3156
Mailing Address - Fax:
Practice Address - Street 1:1500 E HIGHWAY 82
Practice Address - Street 2:SUITE -26
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2831
Practice Address - Country:US
Practice Address - Phone:940-736-3156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THERAPEUTIC MASSAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-10
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT101857305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization