Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | LMT-LMT-LIC-15833 | MT |
NPI | 1013579127 |
---|---|
Provider Name | Michael John Nelson |
First Address | Whitefish, MT 59937-2780 |
Second Address | Whitefish, MT 59937-2780 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2019 |
Last Update Date | 28/06/2019 |