1609811306 NPI number — HILLSIDE HEALTH CARE CENTER, LLC

Table of content: (NPI 1609811306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609811306 NPI number — HILLSIDE HEALTH CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HILLSIDE HEALTH CARE CENTER, LLC
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:
1609811306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 HAZELTINE BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHASKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55318-1070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-361-8000
Provider Business Mailing Address Fax Number:
952-361-8058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4718 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59803-1163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-251-5100
Provider Business Practice Location Address Fax Number:
406-251-4278
Provider Enumeration Date:
06/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEICHERT
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
952-361-8000

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  10323 , 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: 0612482 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 840174 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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