Provider Demographics
NPI:1720869829
Name:MOUNTAIN SPORTS ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:MOUNTAIN SPORTS ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, OMD
Authorized Official - Phone:775-783-4930
Mailing Address - Street 1:1528 US HIGHWAY 395 N STE 230
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5226
Mailing Address - Country:US
Mailing Address - Phone:775-783-4930
Mailing Address - Fax:877-731-1939
Practice Address - Street 1:1528 US HIGHWAY 395 N STE 230
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5226
Practice Address - Country:US
Practice Address - Phone:775-783-4930
Practice Address - Fax:877-731-1939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty