1366442717 NPI number — MICHAEL HAMBLOCK

Table of content: (NPI 1366442717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366442717 NPI number — MICHAEL HAMBLOCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL HAMBLOCK
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:
1366442717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3718 E LAKE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BUTTE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59701-4314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-494-7050
Provider Business Mailing Address Fax Number:
406-494-1424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3718 E LAKE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BUTTE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59701-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-494-7050
Provider Business Practice Location Address Fax Number:
406-494-1424
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAMBLOCK
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-494-7050

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  374PT , 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: 0346112 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK8659 . This is a "TRICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: MSF1190526 . This is a "MONTANA STATE FUND" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: CK8659 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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