Provider Demographics
NPI:1912374570
Name:FOX, MICHAEL L (MS RDN LN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:FOX
Suffix:
Gender:M
Credentials:MS RDN LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 FAIRWAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5814
Mailing Address - Country:US
Mailing Address - Phone:406-209-1696
Mailing Address - Fax:
Practice Address - Street 1:2100 FAIRWAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5814
Practice Address - Country:US
Practice Address - Phone:406-209-1696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered