Healthcare Provider Details

I. General information

NPI: 1396082418
Provider Name (Legal Business Name): HENRY MOON CLOUD L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 DIXON AVE
MISSOULA MT
59801-8224
US

IV. Provider business mailing address

1701 MIDDLE BURNT FORK RD
STEVENSVILLE MT
59870-6649
US

V. Phone/Fax

Practice location:
  • Phone: 406-239-4817
  • Fax: 406-728-0978
Mailing address:
  • Phone: 406-239-4817
  • Fax: 406-728-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: