MEDICARE: RIVER MONTANA 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	174400000X	Specialist

General Provider Information

NPI Number	:	1659724342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER MONTANA LLC

Provider Business Mailing Address
First Line	:	217 S EASY ST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-5487
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2875 TINA AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1581
Country	:	US
Telephone Number	:	406-540-2302
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. EDWARD LESOFSKI
Credential	:
Telephone Number	:	406-540-2302

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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Directions to “RIVER MONTANA LLC ” Practice Location

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