| Organization Name: | MOUNTAIN SAGE HOLISTIC CLINIC, LLC |
| NPI Number: | 1376924621 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARTIN P BAUM (BUSINESS MANAGER) |
| Mailing Address: | 1428 Warm Springs Dr Dubois |
| State: | WY US |
| Postal Code: | 825131428 |
| Phone Number: | 3074552807 |
| Fax Number: | 3074552809 |
| NPI Enumeration Date: | 06/12/2015 |
| NPI Last Update Date: | 06/12/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP2300X |
| License Number: | 33105.1295 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |