Healthcare Provider Details

I. General information

NPI: 1881031862
Provider Name (Legal Business Name): LAME DEER HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHEYENNE AVENUE
LAME DEER MT
59043-9043
US

IV. Provider business mailing address

PO BOX 70
LAME DEER MT
59043-0070
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-4497
  • Fax: 406-477-4427
Mailing address:
  • Phone: 406-477-4497
  • Fax: 406-477-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberNUR-RN-LIC 68698
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number578030
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberR 0055229
License Number StateOK

VIII. Authorized Official

Name: MRS. TINA MARIE CADY
Title or Position: ACCOUNTS RECEIVABLE
Credential:
Phone: 406-477-4497