Healthcare Provider Details

I. General information

NPI: 1205885142
Provider Name (Legal Business Name): MISSOULA SLEEP MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BROOKS ST SUITE 201
MISSOULA MT
59801-5783
US

IV. Provider business mailing address

910 BROOKS ST SUITE 201
MISSOULA MT
59801-5783
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-8053
  • Fax: 406-541-8062
Mailing address:
  • Phone: 406-829-8053
  • Fax: 406-541-8062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC108330
License Number StateMT

VIII. Authorized Official

Name: RICK B WALL
Title or Position: MEMBER
Credential:
Phone: 406-829-8053