Provider Demographics
NPI:1487942058
Name:WESTERN MONTANA SPINE & INJURY CLINIC PLLC
Entity type:Organization
Organization Name:WESTERN MONTANA SPINE & INJURY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-541-7763
Mailing Address - Street 1:2409 DEARBORN AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2409 DEARBORN AVE
Practice Address - Street 2:SUITE I
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7586
Practice Address - Country:US
Practice Address - Phone:406-541-7763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1219305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization