Provider Demographics
NPI:1275701351
Name:BOZEMAN SKIN CLINIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BOZEMAN SKIN CLINIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:TKACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-587-5442
Mailing Address - Street 1:300 N WILLSON AVE
Mailing Address - Street 2:SUITE 203B
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3551
Mailing Address - Country:US
Mailing Address - Phone:406-587-5442
Mailing Address - Fax:
Practice Address - Street 1:300 N WILLSON AVE
Practice Address - Street 2:SUITE 203B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3551
Practice Address - Country:US
Practice Address - Phone:406-587-5442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3871261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty