Healthcare Provider Details

I. General information

NPI: 1285769786
Provider Name (Legal Business Name): MISSOULA URBAN INDIAN HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 W CENTRAL AVE
MISSOULA MT
59801-7931
US

IV. Provider business mailing address

830 W CENTRAL AVE
MISSOULA MT
59801-7931
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-9515
  • Fax: 406-829-9519
Mailing address:
  • Phone: 406-829-9515
  • Fax: 406-829-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number224-15
License Number StateMT

VIII. Authorized Official

Name: MS. LEEANN BRUISED HEAD
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 406-829-9515