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General NPI Number Information
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NPI Number | 1588396675
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Entity Type | Organization
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Legal Business Name | BLACK DOG PERFORMANCE, LLC
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Dates
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Enumeration Date | 06/28/2022
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Last Update Date | 06/28/2022
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Provider Practice Location Address
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Address Line | 2245 W KOCH ST STE A
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City | BOZEMAN
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State | MT
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Zip | 59718-4013
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Country | US
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Telephone | 406-585-7000
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10261
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City | BOZEMAN
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State | MT
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Zip | 59719-0261
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Country | US
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Telephone | 425-686-4349
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. BRENNA ADELE DWYER
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Credential | LMT
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Telephone | 425-686-4349
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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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