MEDICARE: MISSOURI CONSUMER DIRECT, 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1740559590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI CONSUMER DIRECT, LLC

Provider Business Mailing Address
First Line	:	1903 S RUSSELL ST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-6603
Country	:	US
Telephone Number	:	406-532-1900
Fax Number	:	406-532-1901

Provider Business Practice Location Address
First Line	:	1903 S RUSSELL ST
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-6603
Country	:	US
Telephone Number	:	406-532-1900
Fax Number	:	406-532-1901

Authorized Official
Title or Position	:	VP
Name	:	MR. GREER WOODY
Credential	:
Telephone Number	:	406-532-1900

Provider Enumeration Date	:	12/23/2011
Last Update Date	:	12/27/2011

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