Healthcare Provider Details

I. General information

NPI: 1326487430
Provider Name (Legal Business Name): MISSOULA OSTEOPATHIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 11/10/2022
Certification Date: 10/26/2022
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 TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMED-PHYS-LIC-8667
License Number StateMT

VIII. Authorized Official

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