1760703474 NPI number — INTERMOUNTAIN DEACONNESS HOME FOR CHILDREN

Table of content: (NPI 1760703474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760703474 NPI number — INTERMOUNTAIN DEACONNESS HOME FOR CHILDREN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERMOUNTAIN DEACONNESS HOME FOR CHILDREN
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:
INTERMOUNTAIN CHILD & FAMILY PSYCHOLOGICAL CENTER
Provider Other Organization Name Type Code:
5
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:
1760703474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3240 DREDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELENA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59602-0548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-442-7920
Provider Business Mailing Address Fax Number:
406-442-7949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 2ND AVE W STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-4867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-755-4022
Provider Business Practice Location Address Fax Number:
406-755-4023
Provider Enumeration Date:
06/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CAO
Authorized Official Telephone Number:
406-457-4822

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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