Healthcare Provider Details

I. General information

NPI: 1861761967
Provider Name (Legal Business Name): MAX GARRISON MITCHELL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 H STREET
POPLAR MT
59255-0067
US

IV. Provider business mailing address

107 H STREET
POPLAR MT
59255-0067
US

V. Phone/Fax

Practice location:
  • Phone: 406-768-2156
  • Fax: 406-768-5109
Mailing address:
  • Phone: 406-768-2156
  • Fax: 406-768-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberN-38315
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: