Healthcare Provider Details

I. General information

NPI: 1639552235
Provider Name (Legal Business Name): EAST LAKESIDE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7935 MT HIGHWAY 35 STE 201
BIGFORK MT
59911-5711
US

IV. Provider business mailing address

7935 MT HWY 35 STE 201
BIGFORK MT
59911
US

V. Phone/Fax

Practice location:
  • Phone: 406-837-4357
  • Fax:
Mailing address:
  • Phone: 406-837-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number10172
License Number StateMT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. JILL B RIPLEY
Title or Position: ONWER
Credential: FNP
Phone: 406-755-3751