1013004241 NPI number — MONTANA SPORT AND SPINE LLC

Table of content: (NPI 1013004241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013004241 NPI number — MONTANA SPORT AND SPINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTANA SPORT AND SPINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BOZEMAN SPORT AND SPINE LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013004241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 HIGHLAND BLVD, SUITE 1130
Provider Second Line Business Mailing Address:
MONTANA SPORT AND SPINE LLC
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59715-6900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-522-9067
Provider Business Mailing Address Fax Number:
406-522-9074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
925 HIGHLAND BLVD, SUITE 1130
Provider Second Line Business Practice Location Address:
BOZEMAN SPORT AND SPINE LLC
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-6900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-522-9067
Provider Business Practice Location Address Fax Number:
406-522-9074
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AYLOR
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PROPRIETER
Authorized Official Telephone Number:
406-522-9067

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  10381 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000099205 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: DC7699 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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