Provider Demographics
NPI:1831370378
Name:STILLWATER SPINE & SPORTS CENTER, INC.
Entity type:Organization
Organization Name:STILLWATER SPINE & SPORTS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYE
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEDUC
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-756-7634
Mailing Address - Street 1:3171 HWY 93 N
Mailing Address - Street 2:SUITE C
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-756-7634
Mailing Address - Fax:406-756-7643
Practice Address - Street 1:3171 HWY 93 N
Practice Address - Street 2:SUITE C
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-756-7634
Practice Address - Fax:406-756-7643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1014111NS0005X
111NS0005X, 175F00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000084625OtherMEDICARE GROUP