Healthcare Provider Details

I. General information

NPI: 1104097351
Provider Name (Legal Business Name): GRIZZLY SPINE PAIN AND REHAB, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MERIDIAN CT SUITE 2
KALISPELL MT
59901-4240
US

IV. Provider business mailing address

3 MERIDIAN CT SUITE 2
KALISPELL MT
59901-4240
US

V. Phone/Fax

Practice location:
  • Phone: 406-755-4488
  • Fax: 406-755-4481
Mailing address:
  • Phone: 406-755-4488
  • Fax: 406-755-4481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number10947
License Number StateMT

VIII. Authorized Official

Name: SCOTT RICHARD JAHNKE
Title or Position: DOCTOR - OWNER
Credential: DO
Phone: 406-755-4488