Provider Demographics
NPI:1215442611
Name:GLACIER SALT CAVE AND SPA
Entity type:Organization
Organization Name:GLACIER SALT CAVE AND SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-723-9491
Mailing Address - Street 1:917 GLACIER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1883
Mailing Address - Country:US
Mailing Address - Phone:907-723-9491
Mailing Address - Fax:
Practice Address - Street 1:917 GLACIER AVE STE 101
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1883
Practice Address - Country:US
Practice Address - Phone:907-723-9491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1016699225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty