Healthcare Provider Details

I. General information

NPI: 1831233790
Provider Name (Legal Business Name): LARRY W WUNDROW MS, AUDIOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S ORANGE ST
MISSOULA MT
59801-2611
US

IV. Provider business mailing address

601 S ORANGE ST
MISSOULA MT
59801-2611
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-1951
  • Fax: 406-542-5682
Mailing address:
  • Phone: 406-549-1951
  • Fax: 406-542-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number178
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number114
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: