Healthcare Provider Details

I. General information

NPI: 1184956047
Provider Name (Legal Business Name): JAMISUN SKY VAN HORN LAC, LMT, NCBTMB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. SKY VAN HORN

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5603 ARAPAHOE AVE STE 5
BOULDER CO
80303-1377
US

IV. Provider business mailing address

1455 ALPINE AVE
BOULDER CO
80304-3505
US

V. Phone/Fax

Practice location:
  • Phone: 720-989-1513
  • Fax:
Mailing address:
  • Phone: 303-919-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4550
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0002084
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: