Healthcare Provider Details

I. General information

NPI: 1376606517
Provider Name (Legal Business Name): POWDER RIVER PUBLICHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 N. LINCOLN
BROADUS MT
59317-0210
US

IV. Provider business mailing address

PO BOX 210 507 N. LINCOLN
BROADUS MT
59317-0210
US

V. Phone/Fax

Practice location:
  • Phone: 406-436-2297
  • Fax: 406-436-2315
Mailing address:
  • Phone: 406-436-2297
  • Fax: 406-436-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN24922
License Number StateMT

VIII. Authorized Official

Name: MRS. JACI PHILLIPS
Title or Position: RN DIRECTOR
Credential: RN
Phone: 406-436-2297