Healthcare Provider Details

I. General information

NPI: 1669957536
Provider Name (Legal Business Name): TRACY LYNN MIOTKE MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E SEBREE ST
DILLON MT
59725-2733
US

IV. Provider business mailing address

125 S WASHINGTON ST
DILLON MT
59725-2555
US

V. Phone/Fax

Practice location:
  • Phone: 406-925-2220
  • Fax:
Mailing address:
  • Phone: 406-925-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-LMT-LIC-14037
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: