Healthcare Provider Details

I. General information

NPI: 1134421969
Provider Name (Legal Business Name): ORANGE SKYE SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W 6TH ST
PUEBLO CO
81003-3119
US

IV. Provider business mailing address

117 W 6TH ST
PUEBLO CO
81003-3119
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-6400
  • Fax:
Mailing address:
  • Phone: 719-543-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number3296
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6931
License Number StateCO

VIII. Authorized Official

Name: MS. COURTNEY JO LEONARD
Title or Position: CO-OWNER
Credential:
Phone: 719-543-6400