=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417049891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE GOLTZ D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 YELLOWSTONE AVE.
-----------------------------------------------------
City | WEST YELLOWSTONE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59758-1167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-646-4444
-----------------------------------------------------
Fax | 406-646-0030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1167
-----------------------------------------------------
City | WEST YELLOWSTONE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59758-1167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-646-4444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 940
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------