Provider Demographics
NPI:1720686736
Name:MOUNTAIN SAGE ACUPUNCTURE PLLC
Entity Type:Organization
Organization Name:MOUNTAIN SAGE ACUPUNCTURE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:INGE
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-531-0689
Mailing Address - Street 1:PO BOX 9153
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-9153
Mailing Address - Country:US
Mailing Address - Phone:406-531-0689
Mailing Address - Fax:
Practice Address - Street 1:200 E PINE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4513
Practice Address - Country:US
Practice Address - Phone:406-531-0689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT18802OtherSTATE MEDICAL ACUPUNCTURE LICENSE