1255351862 NPI number — RIVERSIDE FAMILY CLINIC

Table of content: DANIEL WAYNE BROWN JR. RADT (NPI 1982173274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255351862 NPI number — RIVERSIDE FAMILY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE FAMILY CLINIC
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:
1255351862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/16/2018
NPI Reactivation Date:
06/11/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 1/2 H ST EAST
Provider Second Line Business Mailing Address:
PO BOX 629
Provider Business Mailing Address City Name:
POPLAR
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59255-0629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-768-5171
Provider Business Mailing Address Fax Number:
406-768-6161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 H ST EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59255-0629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-768-5171
Provider Business Practice Location Address Fax Number:
406-768-6161
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NORGAARD
Authorized Official First Name:
MARGARET
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
406-768-6133

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , 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: 0720137 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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