Provider Demographics
NPI:1316512049
Name:WISE MOUNTAIN MEDICINE LLC
Entity type:Organization
Organization Name:WISE MOUNTAIN MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KELCH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:970-406-1019
Mailing Address - Street 1:2150 NW HILL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1373
Mailing Address - Country:US
Mailing Address - Phone:970-406-1019
Mailing Address - Fax:
Practice Address - Street 1:335 NE REVERE AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4059
Practice Address - Country:US
Practice Address - Phone:541-238-7285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center