Healthcare Provider Details

I. General information

NPI: 1720869829
Provider Name (Legal Business Name): MOUNTAIN SPORTS ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 US HIGHWAY 395 N STE 230
GARDNERVILLE NV
89410-5226
US

IV. Provider business mailing address

1528 US HIGHWAY 395 N STE 230
GARDNERVILLE NV
89410-5226
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-4930
  • Fax: 877-731-1939
Mailing address:
  • Phone: 775-783-4930
  • Fax: 877-731-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID WAYNE EDGE
Title or Position: OWNER
Credential: LAC, OMD
Phone: 775-783-4930