Healthcare Provider Details

I. General information

NPI: 1073080461
Provider Name (Legal Business Name): MISSOULA COMMUNITY HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 6TH AVE
SUPERIOR MT
59872-9667
US

IV. Provider business mailing address

PO BOX 66
SUPERIOR MT
59872-0066
US

V. Phone/Fax

Practice location:
  • Phone: 406-822-4841
  • Fax:
Mailing address:
  • Phone: 406-822-4841
  • Fax: 406-822-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACY CONROW-VERVERIS
Title or Position: CFO
Credential:
Phone: 406-822-4841