MEDICARE: JSK NELSON MEDICAL PROFESSIONAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1215409578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JSK NELSON MEDICAL PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	2875 TINA AVE STE 15
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1581
Country	:	US
Telephone Number	:	406-546-4255
Fax Number	:	406-830-3254

Provider Business Practice Location Address
First Line	:	2875 TINA AVE STE 15
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1581
Country	:	US
Telephone Number	:	406-546-4255
Fax Number	:	406-830-3254

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. CHRISTINE ELIZABETH CROYLE
Credential	:
Telephone Number	:	406-546-4255

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	12/28/2018

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