MEDICARE: 1100 TEXAS AVENUE OPERATIONS 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	314000000X	Skilled Nursing Facility	12681	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821043621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1100 TEXAS AVENUE OPERATIONS LLC

Provider Business Mailing 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	:

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	:	ASSISTANT SECRETARY
Name	:	MICHAEL T. BERG
Credential	:
Telephone Number	:	505-468-4752

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	05/17/2016

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Directions to “1100 TEXAS AVENUE OPERATIONS LLC ” Practice Location

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