Healthcare Provider Details

I. General information

NPI: 1326201054
Provider Name (Legal Business Name): FRED WAYNE PICKERING DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13TH STREET
RED LODGE MT
59068-0685
US

IV. Provider business mailing address

PO BOX 685
RED LODGE MT
59068-0685
US

V. Phone/Fax

Practice location:
  • Phone: 406-425-1843
  • Fax:
Mailing address:
  • Phone: 406-425-1843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number891
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: