Provider Demographics
NPI:1912275033
Name:EMERALD MOUNTAIN INC
Entity Type:Organization
Organization Name:EMERALD MOUNTAIN INC
Other - Org Name:EMERALD MOUNTAIN MASSAGE THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:719-205-5114
Mailing Address - Street 1:108 E CHEYENNE RD
Mailing Address - Street 2:#202
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-2504
Mailing Address - Country:US
Mailing Address - Phone:719-205-5114
Mailing Address - Fax:719-475-1880
Practice Address - Street 1:108 E CHEYENNE RD
Practice Address - Street 2:#202
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2504
Practice Address - Country:US
Practice Address - Phone:719-205-5114
Practice Address - Fax:719-475-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-03
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2531261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service