MEDICARE: SYLVAN INTEGRATIVE CARE, 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	363AM0700X	Medical Physician Assistant
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1417808965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYLVAN INTEGRATIVE CARE, LLC

Provider Business Mailing Address
First Line	:	7 MICROWAVE HILL RD STE C
Second Line	:
City	:	CLANCY
State	:	MT
Zip	:	59634-8001
Country	:	US
Telephone Number	:	406-422-0656
Fax Number	:	833-471-4087

Provider Business Practice Location Address
First Line	:	7 MICROWAVE HILL RD STE C
Second Line	:
City	:	CLANCY
State	:	MT
Zip	:	59634-8001
Country	:	US
Telephone Number	:	406-422-0656
Fax Number	:	833-471-4087

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARK DONALD KISHBAUGH
Credential	:	DMSC, PA-C
Telephone Number	:	406-946-2983

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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