=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609401496
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAILYN GILLIS RD, LN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2020
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19750 MT HIGHWAY 91 N
-----------------------------------------------------
City | GLEN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59732-8507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-868-8915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 922
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59771-0922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | MED-NUTR-LIC-79498
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------