=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275852964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBBY'S LODGE OF LOVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2010
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39042 US HIGHWAY 2
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-8103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 140-629-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39042 US HIGHWAY 2
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-8103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 140-629-3333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAUNA LYNN FIRESTONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 14062933334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 0041013001
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------