Provider Demographics
NPI:1558089904
Name:MOUNTAIN STATE MEDICAL MASSAGE
Entity Type:Organization
Organization Name:MOUNTAIN STATE MEDICAL MASSAGE
Other - Org Name:MOUNTAIN STATE MEDICAL MASSAGE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:720-841-1042
Mailing Address - Street 1:4767 S ODESSA ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-3449
Mailing Address - Country:US
Mailing Address - Phone:720-841-1042
Mailing Address - Fax:
Practice Address - Street 1:6970 S HOLLY CIR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-6296
Practice Address - Country:US
Practice Address - Phone:720-841-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty