=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144683475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL MEDISPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2016
-----------------------------------------------------
Last Update Date | 08/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 S CENTRAL AVE
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59270-4127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-488-5000
-----------------------------------------------------
Fax | 844-766-1639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 S CENTRAL AVE
-----------------------------------------------------
City | SIDNEY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59270-4127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-488-5000
-----------------------------------------------------
Fax | 844-766-1639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN/OWNER
-----------------------------------------------------
Name | MICHELLE L. FRANK
-----------------------------------------------------
Credential | APRN, CNP
-----------------------------------------------------
Telephone | 406-488-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NUR APRN LIC 100657
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------