1083947055 NPI number — SUNBURST COMMUNITY SERVICE FOUNDATION, INC

Table of content: (NPI 1083947055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083947055 NPI number — SUNBURST COMMUNITY SERVICE FOUNDATION, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBURST COMMUNITY SERVICE FOUNDATION, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNBURSTS COMMUNITY SERVICE FOUNDATION, INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083947055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2282 HWY 93 S
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-745-8721
Provider Business Mailing Address Fax Number:
406-257-4054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2282 HWY 93 S
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-745-8721
Provider Business Practice Location Address Fax Number:
406-257-4054
Provider Enumeration Date:
09/09/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESTES
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
406-756-8721

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 304 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: 304 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 304 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MT02338 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".