Provider Demographics
NPI:1649514506
Name:MACKINNON, MICHAEL E
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:MACKINNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 TAMARACK DR UNIT 208
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-3167
Mailing Address - Country:US
Mailing Address - Phone:401-575-8214
Mailing Address - Fax:
Practice Address - Street 1:3001 S LINCOLN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-1789
Practice Address - Country:US
Practice Address - Phone:970-875-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist