MOUNTAIN SAGE HOLISTIC CLINIC LLC NPI 1376924621

NPI Information

MOUNTAIN SAGE HOLISTIC CLINIC, LLC is a primary care nurse practitioner in Dubois, WY. MOUNTAIN SAGE HOLISTIC CLINIC, LLC NPI is 1376924621. The provider is registered as an organization entity type and is a single specialty group.

The provider's business location address is:

1428 WARM SPRINGS DR
DUBOIS, WY
ZIP 82513-428
Phone: (307) 455-2807
Fax: (307) 455-2809

The provider's authorized official is Martin P Baum .
The authorized official title is Business Manager and has the following contact phone number (307) 455-2807.

The CLIA number assigned to this NPI record is 53D2084773 - practitioner other with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 6/12/2015 and was last updated on 6/12/2015.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

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