1083738876 NPI number — INNER-MOUNTAIN FAMILY RESOURCES, INC.

Table of content: (NPI 1083738876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083738876 NPI number — INNER-MOUNTAIN FAMILY RESOURCES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNER-MOUNTAIN FAMILY RESOURCES, 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:
Provider Other Organization Name Type Code:
6
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:
1083738876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23812 COUNTY ROAD 30.5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JUNTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81050-9280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
645-645-2598
Provider Business Mailing Address Fax Number:
719-384-7092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
608 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLE FOURCHE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57717-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-892-3039
Provider Business Practice Location Address Fax Number:
605-892-3158
Provider Enumeration Date:
03/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALLIN
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
605-645-2598

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  410411 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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