1528079720 NPI number — STATE OF MONTANA

Table of content: (NPI 1528079720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528079720 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:
MONTANA MENTAL HEALTH NURSING CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1528079720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2012
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 RM 105
Provider Second Line Business Mailing Address:
P O BOX 6429
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:
406-444-4497
Provider Business Mailing Address Fax Number:
406-444-3082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 CASINO CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTOWN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59457-3359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-538-7451
Provider Business Practice Location Address Fax Number:
406-538-2863
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVERETT
Authorized Official First Name:
TEDDI
Authorized Official Middle Name:
Authorized Official Title or Position:
FISCAL MANAGER
Authorized Official Telephone Number:
406-444-4497

Provider Taxonomy Codes

  • Taxonomy code: 310500000X , with the licence number:  10746 , 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: 57-0414 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-2546 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-0197 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57-2676 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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