Healthcare Provider Details

I. General information

NPI: 1609133024
Provider Name (Legal Business Name): MALTA FAMILY HEALTH CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 1/2 CENTRAL AVE
MALTA MT
59538
US

IV. Provider business mailing address

PO BOX 39
MALTA MT
59538-0039
US

V. Phone/Fax

Practice location:
  • Phone: 406-654-2000
  • Fax: 406-654-2135
Mailing address:
  • Phone: 406-654-2000
  • Fax: 406-654-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number25089
License Number StateMT

VIII. Authorized Official

Name: THAD E GIBLETTE
Title or Position: OWNER
Credential: FNP
Phone: 406-654-2000