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Individual

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Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
228 17TH AVE NW, GREAT FALLS, MT 59404-1807
(406) 454-6973
Mailing address
601 1ST AVE N, GREAT FALLS, MT 59401-2510
(406) 454-6973

Taxonomy

Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
10157554
OR

Other

Enumeration date
07/21/2014
Last updated
04/03/2024
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