Healthcare Provider Details

I. General information

NPI: 1003764911
Provider Name (Legal Business Name): MISSION MOUNTAIN RECOVERY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 3RD AVE E
POLSON MT
59860-2113
US

IV. Provider business mailing address

1311 7TH ST E
POLSON MT
59860-4240
US

V. Phone/Fax

Practice location:
  • Phone: 406-319-2082
  • Fax:
Mailing address:
  • Phone: 406-293-0783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSE SMITH
Title or Position: CO/OWNER- DIRECTOR OF OPERATIONS
Credential:
Phone: 406-293-0783