Healthcare Provider Details

I. General information

NPI: 1740364017
Provider Name (Legal Business Name): WESTERN MONTANA CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 7609
MISSOULA MT
59807-7609
US

V. Phone/Fax

Practice location:
  • Phone: 406-721-5600
  • Fax: 406-721-3907
Mailing address:
  • Phone: 406-721-5600
  • Fax: 406-721-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ADAM VANREGENMORTER
Title or Position: LABORATORY DIRECTOR
Credential: PH.D.
Phone: 406-721-5600