MEDICARE: MONTANA MAICHEL LMP, CIMI

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	174400000X	Specialist	MA 60091741	WA

General Provider Information

NPI Number	:	1902139421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONTANA MAICHEL LMP, CIMI

Provider Business Mailing Address
First Line	:	6013 LAKE SAINT CLAIR DR SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98513-9219
Country	:	US
Telephone Number	:	360-402-1788
Fax Number	:

Provider Business Practice Location Address
First Line	:	6013 LAKE SAINT CLAIR DR SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98513-9219
Country	:	US
Telephone Number	:	360-402-1788
Fax Number	:

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

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	09/16/2009

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