Healthcare Provider Details

I. General information

NPI: 1649514506
Provider Name (Legal Business Name): MICHAEL E MACKINNON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 S LINCOLN AVE SUITE A
STEAMBOAT SPRINGS CO
80487-1789
US

IV. Provider business mailing address

465 TAMARACK DR UNIT 208
STEAMBOAT SPRINGS CO
80487-3167
US

V. Phone/Fax

Practice location:
  • Phone: 970-875-2731
  • Fax:
Mailing address:
  • Phone: 401-575-8214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9722
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: