Healthcare Provider Details

I. General information

NPI: 1053291237
Provider Name (Legal Business Name): TINA M VOGT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 09/06/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 FAWN MEADOW LN
KILA MT
59920-8565
US

IV. Provider business mailing address

21 FAWN MEADOWS LN PO BOX 41
KILA MT
59920
US

V. Phone/Fax

Practice location:
  • Phone: 808-755-5225
  • Fax:
Mailing address:
  • Phone: 808-755-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberC1159918
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: