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General NPI Number Information
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NPI Number | 1639982796
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Entity Type | Organization
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Legal Business Name | MISSION VALLEY WELLNESS, PLLC
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 206 MAIN ST SW
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City | RONAN
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State | MT
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Zip | 59864-2705
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Country | US
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Telephone | 406-676-0244
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 252
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City | RONAN
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State | MT
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Zip | 59864-0252
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Country | US
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Telephone | 406-676-0244
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DIAMOND TIEA FERN COURVILLE
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Credential | FNP
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Telephone | 406-676-0244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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