Healthcare Provider Details

I. General information

NPI: 1639126303
Provider Name (Legal Business Name): MISSOULA BONE & JOINT SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 MULLAN RD SUITE B
MISSOULA MT
59808-1811
US

IV. Provider business mailing address

2360 MULLAN RD SUITE B
MISSOULA MT
59808-1811
US

V. Phone/Fax

Practice location:
  • Phone: 406-542-9695
  • Fax: 406-542-9703
Mailing address:
  • Phone: 406-542-9695
  • Fax: 406-542-9703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateMT

VIII. Authorized Official

Name: SAMANTHA SPENCER
Title or Position: CEO
Credential: CEO
Phone: 406-721-4436