1902962103 NPI number — ANACONDA DEER LODGE COUNTY

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 1902962103 NPI number — ANACONDA DEER LODGE COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANACONDA DEER LODGE COUNTY
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:
1902962103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 970
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANACONDA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59711-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-563-7863
Provider Business Mailing Address Fax Number:
406-563-2387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 E 7TH ST STE 1E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACONDA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59711-2953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-563-7863
Provider Business Practice Location Address Fax Number:
406-563-2387
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLTON
Authorized Official First Name:
LAUREN
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH OFFICER
Authorized Official Telephone Number:
406-563-7863

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 290329 . This is a "MIAMI TARGETED CASE MANAG" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 312078 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 290472 . This is a "FOLLOWME TARGETED CASE MA" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 3505931 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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