Healthcare Provider Details

I. General information

NPI: 1306883905
Provider Name (Legal Business Name): LOLO FAMILY PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 US HIGHWAY 93 S
LOLO MT
59847-9689
US

IV. Provider business mailing address

PO BOX 7638
MISSOULA MT
59807-7638
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-0045
  • Fax: 406-327-3065
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number290
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number315
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5353
License Number StateMT

VIII. Authorized Official

Name: JOYCE E STEVENS
Title or Position: DIR OF ANCILLARY & SATELLITE SRVCS
Credential:
Phone: 406-721-5600