Healthcare Provider Details

I. General information

NPI: 1104648211
Provider Name (Legal Business Name): FUNCTIONAL MEDICINE ASSOCIATES OF MONTANA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 COMMONS LOOP STE D
KALISPELL MT
59901-1912
US

IV. Provider business mailing address

195 COMMONS LOOP STE D
KALISPELL MT
59901-1912
US

V. Phone/Fax

Practice location:
  • Phone: 406-501-6570
  • Fax:
Mailing address:
  • Phone: 406-501-6570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY JEAN COBURN
Title or Position: FAMILY NURSE PRACTITIONER/CO-OWNER
Credential: NP-C
Phone: 406-501-6570