Provider Demographics
NPI:1205885142
Name:MISSOULA SLEEP MEDICINE, LLC
Entity type:Organization
Organization Name:MISSOULA SLEEP MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-829-8053
Mailing Address - Street 1:910 BROOKS ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5783
Mailing Address - Country:US
Mailing Address - Phone:406-829-8053
Mailing Address - Fax:406-541-8062
Practice Address - Street 1:910 BROOKS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5783
Practice Address - Country:US
Practice Address - Phone:406-829-8053
Practice Address - Fax:406-541-8062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTC108330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP00431402OtherRR MEDICARE
MT000094581OtherBLUE CROSS/BLUE SHIELD
MT0034408Medicaid
MT000094581OtherBLUE CROSS/BLUE SHIELD