Provider Demographics
NPI:1619109113
Name:MOUNTAIN SPIRIT HEALING ARTS CENTER
Entity Type:Organization
Organization Name:MOUNTAIN SPIRIT HEALING ARTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:RMT
Authorized Official - Phone:303-772-6655
Mailing Address - Street 1:713 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5926
Practice Address - Country:US
Practice Address - Phone:303-772-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1340204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty