Healthcare Provider Details

I. General information

NPI: 1790449668
Provider Name (Legal Business Name): GARRETT MICHAEL THEISEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
GREAT FALLS MT
59402-6701
US

IV. Provider business mailing address

114 76TH ST N APT 214
GREAT FALLS MT
59405-7634
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-4448
  • Fax:
Mailing address:
  • Phone: 701-214-1751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: