MEDICARE: IVY AT DEER LODGE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225100000X	Physical Therapist
2	225X00000X	Occupational Therapist
3	235Z00000X	Speech-Language Pathologist
4	332B00000X	Durable Medical Equipment & Medical Supplies
5	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1356988349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IVY AT DEER LODGE LLC

Provider Business Mailing Address
First Line	:	9429 HARDING AVE # 141
Second Line	:
City	:	SURFSIDE
State	:	FL
Zip	:	33154-2803
Country	:	US
Telephone Number	:	305-912-9260
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 TEXAS AVE
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1829
Country	:	US
Telephone Number	:	406-846-1655
Fax Number	:

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MR. RYAN MORRIS COANE
Credential	:
Telephone Number	:	305-912-9260

Provider Enumeration Date	:	12/09/2019
Last Update Date	:	01/12/2021

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Directions to “IVY AT DEER LODGE LLC ” Practice Location

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