Healthcare Provider Details

I. General information

NPI: 1912203324
Provider Name (Legal Business Name): CHARISSA SAUNDERS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 E 3RD ST
LA JUNTA CO
81050
US

IV. Provider business mailing address

1120 E 3RD ST
LA JUNTA CO
81050
US

V. Phone/Fax

Practice location:
  • Phone: 719-469-5178
  • Fax:
Mailing address:
  • Phone: 719-469-5178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-7594
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: