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General NPI Number Information
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NPI Number | 1215442611
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Entity Type | Organization
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Legal Business Name | GLACIER SALT CAVE AND SPA
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Dates
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Enumeration Date | 12/06/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 917 GLACIER AVE STE 101
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City | JUNEAU
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State | AK
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Zip | 99801-1883
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Country | US
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Telephone | 907-723-9491
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Fax |
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Provider Business Mailing Address
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Address Line | 917 GLACIER AVE STE 101
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City | JUNEAU
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State | AK
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Zip | 99801-1883
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Country | US
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Telephone | 907-723-9491
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RUSSELL LYLE STEVENS
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Credential |
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Telephone | 907-723-9491
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 1016699
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License Number State | AK
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