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General NPI Number Information
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NPI Number | 1558089904
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Entity Type | Organization
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Legal Business Name | MOUNTAIN STATE MEDICAL MASSAGE
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 01/18/2023
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Provider Practice Location Address
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Address Line | 6970 S HOLLY CIR
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City | CENTENNIAL
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State | CO
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Zip | 80112-6296
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Country | US
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Telephone | 720-841-1042
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Fax |
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Provider Business Mailing Address
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Address Line | 4767 S ODESSA ST
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City | CENTENNIAL
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State | CO
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Zip | 80015-3449
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Country | US
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Telephone | 720-841-1042
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JENNY M NICKERSON
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Credential | LMT
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Telephone | 720-841-1042
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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 |
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License Number State |
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