Healthcare Provider Details

I. General information

NPI: 1518337286
Provider Name (Legal Business Name): NORTH CENTRAL INDEPENDENT LIVING SERVICES,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 25TH AVE
BLACK EAGLE MT
59414-1037
US

IV. Provider business mailing address

1120 25TH AVE
BLACK EAGLE MT
59414-1037
US

V. Phone/Fax

Practice location:
  • Phone: 406-452-9834
  • Fax: 406-453-3940
Mailing address:
  • Phone: 406-452-9834
  • Fax: 406-453-3940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TOM OSBORN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 406-452-9834