Healthcare Provider Details

I. General information

NPI: 1215769906
Provider Name (Legal Business Name): DBA PHC RUSSELL ELEMENTARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 S RUSSELL ST
MISSOULA MT
59801-8537
US

IV. Provider business mailing address

401 RAILROAD ST W
MISSOULA MT
59802-4178
US

V. Phone/Fax

Practice location:
  • Phone: 406-370-0487
  • Fax: 406-258-4732
Mailing address:
  • Phone: 406-258-4496
  • Fax: 406-258-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LARA SALAZAR
Title or Position: BILLING MANAGER
Credential:
Phone: 406-258-3360