Provider Demographics
NPI:1356637656
Name:EQUANIMITY HEALTH CARE, P.C.
Entity Type:Organization
Organization Name:EQUANIMITY HEALTH CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:DICELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-582-1111
Mailing Address - Street 1:1188 N 15TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3290
Mailing Address - Country:US
Mailing Address - Phone:406-582-1111
Mailing Address - Fax:406-582-1112
Practice Address - Street 1:1188 N 15TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3290
Practice Address - Country:US
Practice Address - Phone:406-582-1111
Practice Address - Fax:406-582-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011001430Medicare UPIN