Healthcare Provider Details

I. General information

NPI: 1487482543
Provider Name (Legal Business Name): MOUNTAINSIDE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 MAIN ST
STEVENSVILLE MT
59870-2828
US

IV. Provider business mailing address

704 MAIN ST
STEVENSVILLE MT
59870-2828
US

V. Phone/Fax

Practice location:
  • Phone: 406-303-9781
  • Fax: 880-440-2614
Mailing address:
  • Phone: 406-303-9781
  • Fax: 880-440-2614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARSON C GOMEZ
Title or Position: OWNER
Credential: APRN
Phone: 406-303-9781