Healthcare Provider Details

I. General information

NPI: 1245268671
Provider Name (Legal Business Name): VSR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 OLD FORT RD
MISSOULA MT
59804-7422
US

IV. Provider business mailing address

1107 HAZELTINE BLVD SUITE 200
CHASKA MN
55318-1009
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-1300
  • Fax: 406-721-1620
Mailing address:
  • Phone: 952-361-8000
  • Fax: 952-361-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number9908
License Number StateMT

VIII. Authorized Official

Name: MR. JOHN B GOODMAN
Title or Position: PRESIDENT
Credential:
Phone: 952-361-8000