1043276058 NPI number — HILLSIDE HEALTH CARE CENTER, LLC

Table of content: (NPI 1043276058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043276058 NPI number — HILLSIDE HEALTH CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HILLSIDE HEALTH CARE CENTER, LLC
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:
HILLSIDE HEALTH CARE CENTER
Provider Other Organization Name Type Code:
4
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:
1043276058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 HAZELTINE BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-361-8000
Provider Business Mailing Address Fax Number:
952-361-8058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4720 23RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59803-1137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-251-5100
Provider Business Practice Location Address Fax Number:
406-251-4278
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEICHERT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
AUTHORIZD OFFICIAL
Authorized Official Telephone Number:
952-361-8000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  9917 , 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: 610116 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0345020 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0217698 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0532844 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0344890 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0310258 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4074-2 . This is a "BCBS OF MONTANA" identifier . This identifiers is of the category "OTHER".




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