Healthcare Provider Details

I. General information

NPI: 1619916384
Provider Name (Legal Business Name): CITY OF RED LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NORTH BROADWAY
RED LODGE MT
59068
US

IV. Provider business mailing address

PO BOX 290184
WETHERSFIELD CT
06129-0184
US

V. Phone/Fax

Practice location:
  • Phone: 406-446-2320
  • Fax: 406-446-3480
Mailing address:
  • Phone: 860-257-7080
  • Fax: 860-563-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number718
License Number StateMT

VIII. Authorized Official

Name: MRS. MARY T GENTILE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 860-257-7080