Wholly Authentic Life LLC
Organization Active NPI Clinic/Center · Fairfield, MT
NPI 1043930993 · NPPES record last updated Sep 29, 2023
Key facts
- NPI
- 1043930993
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- Legal business name
- WHOLLY AUTHENTIC LIFE LLC
- Practice address
- 201 1St Ave N
Fairfield, MT 59436-9245 - Phone
- (406) 799-2711
- Fax
- (406) 467-3407
- NPI assigned
- Aug 31, 2022
- Organization subpart
- No
Authorized official
- Name
- Mrs. Tammie S Smith, LCPC
- Title
- MBR
- Phone
- (406) 799-2711
Practitioners 1
-
Tammie Sue Smith, LCPC
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MT
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20240322003353 | MT | Part B Supplier - Clinic/Group Practice | 6103263363 |
Receives reassigned benefits from 1 practitioner Practice locations: Fairfield, MT |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | Yes |
Addresses
Primary practice location
201 1St Ave N
Fairfield, MT 59436-9245
Mailing address
PO Box 907
Fairfield, MT 59436-0907
Phone (406) 799-2711
Other providers in Fairfield, MT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 29, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.