Provider Demographics
NPI:1083169825
Name:MELTDOWN DAY SPA
Entity Type:Organization
Organization Name:MELTDOWN DAY SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:SHAPE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:605-520-9320
Mailing Address - Street 1:105 11TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2852
Mailing Address - Country:US
Mailing Address - Phone:605-520-9320
Mailing Address - Fax:
Practice Address - Street 1:105 11TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-2852
Practice Address - Country:US
Practice Address - Phone:605-520-9320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT10532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD=========Medicaid