Healthcare Provider Details

I. General information

NPI: 1518983360
Provider Name (Legal Business Name): SHAMROCK FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 CLARK ST
MILES CITY MT
59301-2726
US

IV. Provider business mailing address

PO BOX 579
MILES CITY MT
59301-0579
US

V. Phone/Fax

Practice location:
  • Phone: 406-234-3824
  • Fax: 406-234-1041
Mailing address:
  • Phone: 406-234-3824
  • Fax: 406-234-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN26836
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4771
License Number StateMT

VIII. Authorized Official

Name: CATHIE S HENNEBERRY
Title or Position: SOLE PROPRIETOR
Credential: ENP
Phone: 406-234-8863