MEDICARE: WESTERN TRAILS FAMILY MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1205223740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN TRAILS FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	1463 17TH AVE
Second Line	:
City	:	MITCHELL
State	:	NE
Zip	:	69357-1429
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:	308-623-1315

Provider Business Practice Location Address
First Line	:	1463 17TH AVE
Second Line	:
City	:	MITCHELL
State	:	NE
Zip	:	69357-1429
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:	308-623-1313

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHN WESLY BOWLIN
Credential	:	PT, DPT
Telephone Number	:	308-623-1313

Provider Enumeration Date	:	04/22/2015
Last Update Date	:	04/22/2015

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