Provider Demographics
NPI:1548538259
Name:MISTY'S TANNING AND ULTIMATE SALON
Entity type:Organization
Organization Name:MISTY'S TANNING AND ULTIMATE SALON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-7500
Mailing Address - Street 1:PO BOX 1211
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-1211
Mailing Address - Country:US
Mailing Address - Phone:406-543-0717
Mailing Address - Fax:
Practice Address - Street 1:3101 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6872
Practice Address - Country:US
Practice Address - Phone:406-543-0717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty