Healthcare Provider Details

I. General information

NPI: 1437143484
Provider Name (Legal Business Name): HOSPICE OF MISSOULA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KENSINGTON AVE SUITE 209
MISSOULA MT
59801-5674
US

IV. Provider business mailing address

800 KENSINGTON AVE SUITE 209
MISSOULA MT
59801-5674
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-4408
  • Fax: 406-543-4418
Mailing address:
  • Phone: 406-543-4408
  • Fax: 406-543-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number9596
License Number StateMT

VIII. Authorized Official

Name: GREGORY JACKSON
Title or Position: OWNER
Credential:
Phone: 406-543-4408