Provider Demographics
NPI:1295577047
Name:FAITHFUL MODALITIES MEDICAL MASSAGE LLC
Entity type:Organization
Organization Name:FAITHFUL MODALITIES MEDICAL MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALER-MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:361-502-1793
Mailing Address - Street 1:5900 BALCONES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 RAILROAD DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-1539
Practice Address - Country:US
Practice Address - Phone:361-502-1793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-12
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty