1205875978 NPI number — LAKESIDE QRU, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205875978 NPI number — LAKESIDE QRU, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE QRU, 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:
1205875978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59917-2458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-297-1627
Provider Business Mailing Address Fax Number:
406-297-4144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 BILLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-844-2775
Provider Business Practice Location Address Fax Number:
406-844-3663
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OWEN
Authorized Official First Name:
JORDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
406-844-2775

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  152 , 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: 657682 . This is a "BC BS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 65762 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0442238 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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