Provider Demographics
NPI:1679164149
Name:MOUNTAIN STATES PRECISION HEALTHCARE PLLC
Entity Type:Organization
Organization Name:MOUNTAIN STATES PRECISION HEALTHCARE PLLC
Other - Org Name:MOUNTAIN STATES PRECISION HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-459-0334
Mailing Address - Street 1:2004 SILVER TIPS DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8602
Mailing Address - Country:US
Mailing Address - Phone:206-459-0334
Mailing Address - Fax:219-244-6019
Practice Address - Street 1:2825 STOCKYARD RD STE A18
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1545
Practice Address - Country:US
Practice Address - Phone:406-219-1233
Practice Address - Fax:219-244-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care