MEDICARE: KALISPELL DIAGNOSTIC SERVICE INC

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	207R00000X	Internal Medicine Physician
2	207RN0300X	Nephrology Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	C43672	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8607	OTHER	MT	BCBS

General Provider Information

NPI Number	:	1891894317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALISPELL DIAGNOSTIC SERVICE INC

Provider Business Mailing Address
First Line	:	135 COMMONS WAY
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1900
Country	:	US
Telephone Number	:	406-752-7406
Fax Number	:	406-752-7544

Provider Business Practice Location Address
First Line	:	135 COMMONS WAY
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1900
Country	:	US
Telephone Number	:	406-752-7406
Fax Number	:	406-752-7544

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	KAREN D LARSON
Credential	:
Telephone Number	:	406-752-7582

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	03/04/2014

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Directions to “KALISPELL DIAGNOSTIC SERVICE INC ” Practice Location

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