1104002922 NPI number — FORT BELKNAP EMERGENCY MEDICAL SERVICES

Table of content: (NPI 1104002922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104002922 NPI number — FORT BELKNAP EMERGENCY MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT BELKNAP EMERGENCY MEDICAL SERVICES
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:
Provider Other Organization Name Type Code:
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:
1104002922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 BURLINGTON AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801-5681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-549-7104
Provider Business Mailing Address Fax Number:
406-542-2785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RR 1 BOX 67
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARLEM
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59526-9705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-549-7104
Provider Business Practice Location Address Fax Number:
406-542-2785
Provider Enumeration Date:
01/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
UNGARETTI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
406-549-7104

Provider Taxonomy Codes

  • Taxonomy code: 344600000X , with the licence number:  T-05.28PCN , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0540532 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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