Healthcare Provider Details

I. General information

NPI: 1659431013
Provider Name (Legal Business Name): WALLACE S. WILDER MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 SUNNYVIEW LN SUITE 103
KALISPELL MT
59901-3135
US

IV. Provider business mailing address

210 SUNNYVIEW LN SUITE 103
KALISPELL MT
59901-3135
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8300
  • Fax: 406-752-3542
Mailing address:
  • Phone: 406-752-8300
  • Fax: 406-752-3542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3655
License Number StateMT

VIII. Authorized Official

Name: MRS. TRUDY B. WAGGENER
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-752-8300