Healthcare Provider Details

I. General information

NPI: 1467381772
Provider Name (Legal Business Name): MYLES MATTHEW EKSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 N 14TH AVE UNIT A
BOZEMAN MT
59715-3475
US

IV. Provider business mailing address

217 SILVER CLOUD CIR
BOZEMAN MT
59715-0631
US

V. Phone/Fax

Practice location:
  • Phone: 406-586-4678
  • Fax: 406-586-4670
Mailing address:
  • Phone: 406-551-0699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPRD-PT-LIC-31658
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: