Healthcare Provider Details

I. General information

NPI: 1699867051
Provider Name (Legal Business Name): LAKE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 MAIN ST SUITE A
POLSON MT
59860-3201
US

IV. Provider business mailing address

106 4TH AVE E
POLSON MT
59860-2133
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-7288
  • Fax: 406-883-7290
Mailing address:
  • Phone: 406-883-7288
  • Fax: 406-883-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number StateMT

VIII. Authorized Official

Name: EMILY COLOMEDA
Title or Position: HEALTH SERVICES DIRECTOR
Credential: RN
Phone: 406-883-7288