MEDICARE: HEADWATERS PALLIATIVE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SH0200X	Home Health Clinical Nurse Specialist

General Provider Information

NPI Number	:	1245052299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEADWATERS PALLIATIVE SERVICES

Provider Business Mailing Address
First Line	:	2625 WINNE AVE STE A1
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-4958
Country	:	US
Telephone Number	:	406-422-0114
Fax Number	:	406-324-9190

Provider Business Practice Location Address
First Line	:	2625 WINNE AVE STE A1
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-4958
Country	:	US
Telephone Number	:	406-422-0114
Fax Number	:	406-324-9190

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL BROWN
Credential	:
Telephone Number	:	406-422-0114

Provider Enumeration Date	:	10/30/2024
Last Update Date	:	10/30/2024

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