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General NPI Number Information
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NPI Number | 1205875978
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Entity Type | Organization
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Legal Business Name | LAKESIDE QRU, INC
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 05/19/2020
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Provider Practice Location Address
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Address Line | 201 BILLS RD
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City | LAKESIDE
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State | MT
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Zip | 59922
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Country | US
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Telephone | 406-844-2775
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Fax | 406-844-3663
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Provider Business Mailing Address
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Address Line | PO BOX 2458
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City | EUREKA
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State | MT
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Zip | 59917-2458
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Country | US
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Telephone | 406-297-1627
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Fax | 406-297-4144
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JORDAN OWEN
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Credential |
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Telephone | 406-844-2775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | 152
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License Number State | MT
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