Provider Demographics
NPI:1619007101
Name:MONTANA HEART ANGIO LAB LLC
Entity Type:Organization
Organization Name:MONTANA HEART ANGIO LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-327-4131
Mailing Address - Street 1:2827 FORT MISSOULA RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7408
Mailing Address - Country:US
Mailing Address - Phone:406-327-4614
Mailing Address - Fax:406-327-4679
Practice Address - Street 1:2827 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7408
Practice Address - Country:US
Practice Address - Phone:406-327-4614
Practice Address - Fax:406-327-4679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT71253291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory