Healthcare Provider Details

I. General information

NPI: 1154939643
Provider Name (Legal Business Name): JOHN ROBERT POWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD BLDG 2040
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

6404 MAGNOLIA DR
GREAT FALLS MT
59405-6807
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-4633
  • Fax:
Mailing address:
  • Phone: 402-212-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: