=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366308140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PONDEROSA HEALING WATERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2025
-----------------------------------------------------
Last Update Date | 12/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 1ST AVE
-----------------------------------------------------
City | ST IGNATIUS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59865-7748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-880-7305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1016
-----------------------------------------------------
City | ST IGNATIUS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59865-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-880-7305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAC, SWLC, OWNER
-----------------------------------------------------
Name | ANGELA CHRISTINE EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-880-7305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------