Healthcare Provider Details

I. General information

NPI: 1205875978
Provider Name (Legal Business Name): LAKESIDE QRU, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BILLS RD
LAKESIDE MT
59922
US

IV. Provider business mailing address

PO BOX 2458
EUREKA MT
59917-2458
US

V. Phone/Fax

Practice location:
  • Phone: 406-844-2775
  • Fax: 406-844-3663
Mailing address:
  • Phone: 406-297-1627
  • Fax: 406-297-4144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number152
License Number StateMT

VIII. Authorized Official

Name: JORDAN OWEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 406-844-2775