MEDICARE: HILLSIDE HEALTH CARE CENTER, LLC

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	3336L0003X	Long Term Care Pharmacy	755	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2703785	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1265597207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HILLSIDE HEALTH CARE CENTER, LLC

Provider Business Mailing Address
First Line	:	1107 HAZELTINE BLVD STE 200
Second Line	:
City	:	CHASKA
State	:	MN
Zip	:	55318-1070
Country	:	US
Telephone Number	:	952-361-8000
Fax Number	:	952-361-8060

Provider Business Practice Location Address
First Line	:	4720 23RD AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-1137
Country	:	US
Telephone Number	:	406-251-5100
Fax Number	:	406-251-4278

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	JAMES A. WEICHERT
Credential	:
Telephone Number	:	952-361-8000

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	10/16/2017

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