Provider Demographics
NPI:1366859464
Name:THE SPA AT THE PEAK
Entity Type:Organization
Organization Name:THE SPA AT THE PEAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-251-8200
Mailing Address - Street 1:5000 BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-9213
Mailing Address - Country:US
Mailing Address - Phone:406-251-8200
Mailing Address - Fax:406-251-3332
Practice Address - Street 1:5000 BLUE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-9213
Practice Address - Country:US
Practice Address - Phone:406-251-8200
Practice Address - Fax:406-251-3332
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK HEALTH AND WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-21
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCOS-SLN-LIC-4359174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty