Provider Demographics
NPI:1053692376
Name:AESCULAP THERAPEUTIC & SPORTS MASSAGE, LLC
Entity type:Organization
Organization Name:AESCULAP THERAPEUTIC & SPORTS MASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC MASSAGE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:URSULA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT-JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LBMT
Authorized Official - Phone:609-771-0476
Mailing Address - Street 1:1901 N OLDEN AVENUE EXT
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-2111
Mailing Address - Country:US
Mailing Address - Phone:609-771-0476
Mailing Address - Fax:
Practice Address - Street 1:1901 N OLDEN AVENUE EXT
Practice Address - Street 2:SUITE 4
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08618-2111
Practice Address - Country:US
Practice Address - Phone:609-771-0476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00416500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12360257OtherCAQH
NJ1730468687OtherNPI