Healthcare Provider Details

I. General information

NPI: 1619109113
Provider Name (Legal Business Name): MOUNTAIN SPIRIT HEALING ARTS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 3RD AVE
LONGMONT CO
80501-5926
US

IV. Provider business mailing address

713 3RD AVE
LONGMONT CO
80501-5926
US

V. Phone/Fax

Practice location:
  • Phone: 303-772-6655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number1340
License Number StateCO

VIII. Authorized Official

Name: SUSAN MALIN
Title or Position: OWNER/MASSAGE THERAPIST
Credential: RMT
Phone: 303-772-6655