1962274662 NPI number — MRS. ELLIE VICTORIA SHATTUCK PCLC

Table of content: MRS. IRINA GRUBOY PA-C, PHD (NPI 1861469009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962274662 NPI number — MRS. ELLIE VICTORIA SHATTUCK PCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHATTUCK
Provider First Name:
ELLIE
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
ELLIE
Provider Other Middle Name:
VICTORIA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962274662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 WESTGATE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59718-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-574-0383
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1970 STADIUM DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-0623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-574-0383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  BBH-PCLC-LIC-48422 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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