Healthcare Provider Details

I. General information

NPI: 1275701351
Provider Name (Legal Business Name): BOZEMAN SKIN CLINIC PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N WILLSON AVE SUITE 203B
BOZEMAN MT
59715-3551
US

IV. Provider business mailing address

300 N WILLSON AVE SUITE 203B
BOZEMAN MT
59715-3551
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-5442
  • Fax:
Mailing address:
  • Phone: 406-587-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number3871
License Number StateMT

VIII. Authorized Official

Name: MR. JOHN R TKACH
Title or Position: PRESIDENT
Credential: MD
Phone: 406-587-5442