Healthcare Provider Details

I. General information

NPI: 1184640104
Provider Name (Legal Business Name): BOHANNON CREEK ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HIGHWAY 91 SOUTH
DILLON MT
59725-3516
US

IV. Provider business mailing address

PO BOX 34940
SEATTLE WA
98124-1940
US

V. Phone/Fax

Practice location:
  • Phone: 406-683-3000
  • Fax:
Mailing address:
  • Phone: 503-372-2740
  • Fax: 503-372-2754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: GORDON H. LUCAS
Title or Position: PRESIDENT
Credential: CRNA
Phone: 503-372-2740