Healthcare Provider Details

I. General information

NPI: 1780491506
Provider Name (Legal Business Name): SCOTT FANDRICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 W COLLEGE ST STE 100
BOZEMAN MT
59715-4915
US

IV. Provider business mailing address

4355 BROOKSIDE LN UNIT B
BOZEMAN MT
59718-6373
US

V. Phone/Fax

Practice location:
  • Phone: 406-556-0562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMT-LIC-6822
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: