Healthcare Provider Details

I. General information

NPI: 1861153280
Provider Name (Legal Business Name): MONTANA SPINE AND NEURODEVELOPMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2593 HWY 2 EAST SUITE 1
KALISPELL MT
59901
US

IV. Provider business mailing address

2593 US HIGHWAY 2 E STE 1
KALISPELL MT
59901-9507
US

V. Phone/Fax

Practice location:
  • Phone: 406-890-2214
  • Fax:
Mailing address:
  • Phone: 406-890-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANGELA WATHAN
Title or Position: PRESIDENT
Credential: DC
Phone: 406-890-2214