=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477375988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARVEST HEALTHCARE MT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2024
-----------------------------------------------------
Last Update Date | 10/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 2ND AVE N STE 520
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59401-3289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-403-4798
-----------------------------------------------------
Fax | 406-743-1622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 9TH AVE S # 6742
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59405-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-403-4798
-----------------------------------------------------
Fax | 406-743-1622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ALICIA HAMILTON
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 406-403-4798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------