Healthcare Provider Details

I. General information

NPI: 1790802593
Provider Name (Legal Business Name): MR. GARY ALAN WINGFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SPEEDWAY AVE
MISSOULA MT
59802-5566
US

IV. Provider business mailing address

1300 SPEEDWAY AVE
MISSOULA MT
59802-5566
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-8127
  • Fax: 406-542-5202
Mailing address:
  • Phone: 406-549-8127
  • Fax: 406-542-5202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number10995
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: