1013744556 NPI number — GERRY LYNN EAGLEMAN CNA

Table of content: GERRY LYNN EAGLEMAN CNA (NPI 1013744556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013744556 NPI number — GERRY LYNN EAGLEMAN CNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EAGLEMAN
Provider First Name:
GERRY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNA
Provider Gender Code:
F

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:
1013744556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 HAYSTACK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOX ELDER
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59521-8905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-945-3663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROCKY BOY HEALTH CENTER
Provider Second Line Business Practice Location Address:
6850 UPPER BOX ELDER RD
Provider Business Practice Location Address City Name:
BOX ELDER
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-395-4486
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X , 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)