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General NPI Number Information
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NPI Number | 1659431013
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Entity Type | Organization
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Legal Business Name | WALLACE S. WILDER MD
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 08/15/2011
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Provider Practice Location Address
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Address Line | 210 SUNNYVIEW LN SUITE 103
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City | KALISPELL
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State | MT
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Zip | 59901-3135
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Country | US
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Telephone | 406-752-8300
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Fax | 406-752-3542
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Provider Business Mailing Address
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Address Line | 210 SUNNYVIEW LN SUITE 103
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City | KALISPELL
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State | MT
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Zip | 59901-3135
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Country | US
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Telephone | 406-752-8300
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Fax | 406-752-3542
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. TRUDY B. WAGGENER
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Credential |
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Telephone | 406-752-8300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 3655
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License Number State | MT
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