1912670795 NPI number — EDEN HOSPICE AT WESTERN MONTANA, LLC

Table of content: (NPI 1912670795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912670795 NPI number — EDEN HOSPICE AT WESTERN MONTANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDEN HOSPICE AT WESTERN MONTANA, 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:
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:
1912670795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 NE 77TH AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-892-6628
Provider Business Mailing Address Fax Number:
360-882-5793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2075 CHARLOTTE ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59718-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-587-8710
Provider Business Practice Location Address Fax Number:
406-587-0627
Provider Enumeration Date:
07/28/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MANAGEMENT, LLC
Authorized Official First Name:
EMPRES HEALTHCARE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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