Healthcare Provider Details

I. General information

NPI: 1912133885
Provider Name (Legal Business Name): MISSOULA OSTEOPATHIC CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 06/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 W PINE ST
MISSOULA MT
59802-4119
US

IV. Provider business mailing address

341 W PINE ST
MISSOULA MT
59802-4119
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-0269
  • Fax: 406-327-0264
Mailing address:
  • Phone: 406-327-0269
  • Fax: 406-327-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number11754
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number11801
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number8667
License Number StateMT

VIII. Authorized Official

Name: SAM A WALLACE
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 406-327-0269