1306883905 NPI number — LOLO FAMILY PRACTICE INC

Table of content: (NPI 1306883905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306883905 NPI number — LOLO FAMILY PRACTICE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOLO FAMILY PRACTICE 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:
LOLO FLORENCE FAMILY PRACTICE
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:
1306883905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59807-7638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11350 US HIGHWAY 93 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOLO
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59847-9689
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-273-0045
Provider Business Practice Location Address Fax Number:
406-327-3065
Provider Enumeration Date:
06/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
JOYCE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DIR OF ANCILLARY & SATELLITE SRVCS
Authorized Official Telephone Number:
406-721-5600

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  290 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 5353 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 315 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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