1356351183 NPI number — STATE OF MONTANA

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 1356351183 NPI number — STATE OF MONTANA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF MONTANA
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:
1356351183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 N SANDERS ST DEPT 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELENA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59601-4520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-444-3416
Provider Business Mailing Address Fax Number:
406-444-3082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 VETERANS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59912-0250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-892-3256
Provider Business Practice Location Address Fax Number:
406-892-0256
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
ALEASHA
Authorized Official Middle Name:
Authorized Official Title or Position:
FACILITY REIMBURSEMENT MANAGER
Authorized Official Telephone Number:
406-444-3416

Provider Taxonomy Codes

  • 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: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 10640 , 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: 57-0129 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0163 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0146 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0323 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0219 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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