Basic Information
| Provider Information | |||||||||
| NPI: | 1740364017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN MONTANA CLINIC PC | ||||||||
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| OtherOrganizationName: | WESTERN MONTANA CLINIC LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7609 | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598077609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067215600 | ||||||||
| FaxNumber: | 4067213907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | VANREGENMORTER | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4067215600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.