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General NPI Number Information
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NPI Number | 1013658566
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Entity Type | Organization
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Legal Business Name | CLEARWATER CHIROPRACTIC PC
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Dates
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Enumeration Date | 04/06/2022
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Last Update Date | 04/17/2023
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Provider Practice Location Address
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Address Line | 2330 SOUTH HIGGINS AVE SUITE 100
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City | MISSOULA
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State | MT
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Zip | 59801-6923
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Country | US
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Telephone | 406-728-0330
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Fax | 406-728-0330
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Provider Business Mailing Address
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Address Line | 2330 SOUTH HIGGINS AVE SUITE 100
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City | MISSOULA
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State | MT
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Zip | 59801-6923
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Country | US
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Telephone | 406-728-0330
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Fax | 406-728-0330
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | GLEN MARICELLI
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Credential | D.C
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Telephone | 406-550-3493
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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