Healthcare Provider Details

I. General information

NPI: 1821043621
Provider Name (Legal Business Name): 1100 TEXAS AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 TEXAS AVE
DEER LODGE MT
59722-1829
US

IV. Provider business mailing address

1100 TEXAS AVE
DEER LODGE MT
59722-1829
US

V. Phone/Fax

Practice location:
  • Phone: 406-846-1655
  • Fax:
Mailing address:
  • Phone: 406-846-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number12681
License Number StateMT

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752