Organization
CLINICAL LABORATORY SERVICE
Active
Other names
Medical Laboratory Service
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL W GARD (CFO)
(406) 586-2040
Entity
Organization
Contact information
Practice address
300 N WILSON ST, STE 1001, BOZEMAN, MT 59715
(406) 586-2040
(406) 586-5577
Mailing address
300 N WILLSON AVE, STE 1001, BOZEMAN, MT 59715-3551
(406) 586-2040
(406) 586-5577
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
0700410684
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0420173
—
MT
01
—
2700410684
CLIA
MT
01
—
M000002428
MEDICARE PTAN
MT
Enumeration date
08/04/2006
Last updated
07/17/2009
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