Healthcare Provider Details

I. General information

NPI: 1447244140
Provider Name (Legal Business Name): FIELD OF DREAMS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 W MAIN ST
BOZEMAN MT
59715-3219
US

IV. Provider business mailing address

1006 W MAIN ST
BOZEMAN MT
59715-3219
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-8711
  • Fax: 406-587-2602
Mailing address:
  • Phone: 406-586-8711
  • Fax: 406-587-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4048
License Number StateMT

VIII. Authorized Official

Name: DR. JOHN MICHAEL WISE
Title or Position: DIRECTOR
Credential: MD
Phone: 406-586-8711