Healthcare Provider Details

I. General information

NPI: 1326123696
Provider Name (Legal Business Name): PLENTYWOOD CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 W LAUREL AVE
PLENTYWOOD MT
59254-1526
US

IV. Provider business mailing address

PO BOX 217
PLENTYWOOD MT
59254-0217
US

V. Phone/Fax

Practice location:
  • Phone: 406-765-1501
  • Fax: 406-765-1506
Mailing address:
  • Phone: 406-765-1501
  • Fax: 406-765-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CINDY S NIKOLAISEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-765-1501