Provider Demographics
NPI:1104119395
Name:PACK, ROY E JR (BS)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:E
Last Name:PACK
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 JUNIPER AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044-2512
Mailing Address - Country:US
Mailing Address - Phone:406-702-3455
Mailing Address - Fax:
Practice Address - Street 1:614 JUNIPER AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044-2512
Practice Address - Country:US
Practice Address - Phone:406-702-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MT171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator