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General NPI Number Information
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NPI Number | 1982873287
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Entity Type | Organization
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Legal Business Name | MISTY MOUNTAIN MEDICINE
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 10/25/2010
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Provider Practice Location Address
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Address Line | 3555 MERRIMENT WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80917-2557
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Country | US
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Telephone | 505-366-4033
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 26111
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City | COLORADO SPRINGS
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State | CO
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Zip | 80936-6111
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Country | US
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Telephone | 505-366-4033
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LACRETIA YVONNE BAJWA
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Credential | DOM
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Telephone | 505-366-4033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 1613
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License Number State | CO
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