MEDICARE: MR. RYAN J. FRIELDS LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1419	MT

General Provider Information

NPI Number	:	1497023451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN J. FRIELDS LAC

Provider Business Mailing Address
First Line	:	PO BOX 905
Second Line	:
City	:	THOMPSON FALLS
State	:	MT
Zip	:	59873-0905
Country	:	US
Telephone Number	:	406-396-5346
Fax Number	:

Provider Business Practice Location Address
First Line	:	396 BIG BEAVER CREEK RD
Second Line	:
City	:	TROUT CREEK
State	:	MT
Zip	:	59874-9630
Country	:	US
Telephone Number	:	406-396-5346
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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