Provider Demographics
NPI:1902072572
Name:WOMACK, DOUGLAS KEITH (LAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:KEITH
Last Name:WOMACK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W BROADWAY ST
Mailing Address - Street 2:SUITE 101-523
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4136
Mailing Address - Country:US
Mailing Address - Phone:406-541-2399
Mailing Address - Fax:
Practice Address - Street 1:320A EXPRESSWAY STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1560
Practice Address - Country:US
Practice Address - Phone:406-541-2399
Practice Address - Fax:406-541-2398
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT211171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist