Provider Demographics
NPI:1154939643
Name:POWELL, JOHN ROBERT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-6807
Mailing Address - Country:US
Mailing Address - Phone:402-212-0769
Mailing Address - Fax:
Practice Address - Street 1:7300 N PERIMETER RD BLDG 2040
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402-6701
Practice Address - Country:US
Practice Address - Phone:406-731-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians