Provider Demographics
NPI:1891894317
Name:KALISPELL DIAGNOSTIC SERVICE INC
Entity type:Organization
Organization Name:KALISPELL DIAGNOSTIC SERVICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-7582
Mailing Address - Street 1:135 COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1900
Mailing Address - Country:US
Mailing Address - Phone:406-752-7406
Mailing Address - Fax:406-752-7544
Practice Address - Street 1:135 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1900
Practice Address - Country:US
Practice Address - Phone:406-752-7406
Practice Address - Fax:406-752-7544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT8607OtherBCBS
C43672OtherRR MEDICARE
C43672OtherRR MEDICARE