Healthcare Provider Details

I. General information

NPI: 1023011590
Provider Name (Legal Business Name): WIBAUX COUNTY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 WIBAUX ST S
WIBAUX MT
59353-9022
US

IV. Provider business mailing address

712 WIBAUX ST S
WIBAUX MT
59353-9022
US

V. Phone/Fax

Practice location:
  • Phone: 406-796-2429
  • Fax: 406-796-8109
Mailing address:
  • Phone: 406-796-2429
  • Fax: 406-796-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number10055
License Number StateMT

VIII. Authorized Official

Name: TINA BERTELSEN
Title or Position: BUSINESS OFFICE MANAGER
Credential: NHA/BOM
Phone: 406-796-2429