Provider Demographics
NPI:1699806471
Name:WEST YELLOWSTONE BACK & NECK CLINIC
Entity Type:Organization
Organization Name:WEST YELLOWSTONE BACK & NECK CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-646-4444
Mailing Address - Street 1:PO BOX 1167
Mailing Address - Street 2:
Mailing Address - City:WEST YELLOWSTONE
Mailing Address - State:MT
Mailing Address - Zip Code:59758-1167
Mailing Address - Country:US
Mailing Address - Phone:406-646-4444
Mailing Address - Fax:
Practice Address - Street 1:425 YELLOWSTONE AVE.
Practice Address - Street 2:
Practice Address - City:WEST YELLOWSTONE
Practice Address - State:MT
Practice Address - Zip Code:59758
Practice Address - Country:US
Practice Address - Phone:406-646-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT940261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000004537Medicare ID - Type Unspecified
MTM000004537Medicare PIN
MTU79767Medicare UPIN