MEDICARE: LOLO FAMILY PRACTICE INC

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	103T00000X	Psychologist	290	MT
2	363A00000X	Physician Assistant	315	MT
3	207Q00000X	Family Medicine Physician	5353	MT

General Provider Information

NPI Number	:	1306883905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOLO FAMILY PRACTICE INC

Provider Business Mailing Address
First Line	:	PO BOX 7638
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59807-7638
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11350 US HIGHWAY 93 S
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-9689
Country	:	US
Telephone Number	:	406-273-0045
Fax Number	:	406-327-3065

Authorized Official
Title or Position	:	DIR OF ANCILLARY & SATELLITE SRVCS
Name	:	JOYCE E STEVENS
Credential	:
Telephone Number	:	406-721-5600

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	05/15/2008

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Directions to “LOLO FAMILY PRACTICE INC ” Practice Location

Language	Start Address	Practice Location

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