# CENTER FOR MYOFASCIAL THERAPEUTICS AND AESTHETICS

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Brazzale Surgical Assisting LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1932750056
- **Authorized official:** ARIEL BRAZZALE NP (CEO)
- **Authorized official phone:** (219) 669-1034

## Contact information

- **Practice address:** 9430 WICKER AVE, SAINT JOHN, IN 46373-9400
- **Practice address phone:** (219) 558-8068
- **Practice address fax:** (877) 822-9116
- **Mailing address:** 9430 WICKER AVE, SAINT JOHN, IN 46373-9400
- **Mailing address phone:** (219) 558-8068
- **Mailing address fax:** (877) 822-9116

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 246ZC0007X | Surgical Assistant | — | NULL | — |
| 246ZC0007X | Surgical Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | Yes |
| 363L00000X | Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 09/20/2019
- **Last updated:** 08/21/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 71013263A | INDIANA NURSING BOARD LICENSE | IN |