=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619166972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERFORMANCE INJURY CARE & SPORTS MEDICINE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2007
-----------------------------------------------------
Last Update Date | 03/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 N MONTANA AVE SUITE A
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59602-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-422-5817
-----------------------------------------------------
Fax | 406-422-5928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 N MONTANA AVE SUITE A
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59602-7804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-422-5817
-----------------------------------------------------
Fax | 406-422-5928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. JAMIE BRAGG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-422-5817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------