1588722383 NPI number — JEFFERSON COUNTY HEALTH DEPARTMENT

Table of content: (NPI 1588722383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588722383 NPI number — JEFFERSON COUNTY HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFERSON COUNTY HEALTH DEPARTMENT
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:
1588722383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 872
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-225-4007
Provider Business Mailing Address Fax Number:
406-225-4108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOULDER
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-225-4007
Provider Business Practice Location Address Fax Number:
406-225-4108
Provider Enumeration Date:
12/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOBSON WANDEL
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
SUPERVISOR
Authorized Official Telephone Number:
406-225-4009

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , with the licence number:  6901 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X , 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: 3506607 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".