Healthcare Provider Details

I. General information

NPI: 1972811420
Provider Name (Legal Business Name): PREMIER CARE PEDIATRICS & FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2010
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 28TH ST S SUITE 6
GREAT FALLS MT
59405-5296
US

IV. Provider business mailing address

1300 28TH ST S SUITE 6
GREAT FALLS MT
59405-5296
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-5437
  • Fax: 406-455-4365
Mailing address:
  • Phone: 406-455-5437
  • Fax: 406-455-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number8726
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN13634
License Number StateMT

VIII. Authorized Official

Name: MRS. JILL SIMMONS
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-455-5437