Healthcare Provider Details

I. General information

NPI: 1407227655
Provider Name (Legal Business Name): MAVIS DILLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 GRANT DR
GREAT FALLS MT
59404-6222
US

IV. Provider business mailing address

1069 GRANT DR
GREAT FALLS MT
59404-6222
US

V. Phone/Fax

Practice location:
  • Phone: 406-564-7049
  • Fax:
Mailing address:
  • Phone: 406-564-7049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number920112
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number920112
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: