Healthcare Provider Details

I. General information

NPI: 1932700234
Provider Name (Legal Business Name): KORI LALIBERTY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 COLONIAL DR
HELENA MT
59601-4926
US

IV. Provider business mailing address

PO BOX 5539
HELENA MT
59604-5539
US

V. Phone/Fax

Practice location:
  • Phone: 406-444-7500
  • Fax: 406-884-2085
Mailing address:
  • Phone: 406-444-7500
  • Fax: 406-884-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number90533
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: