=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831242577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOHN'S LUTHERAN HOSPITAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 07/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 LOUISIANA AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-0100
-----------------------------------------------------
Fax | 406-293-2453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 LOUISIANA AVE
-----------------------------------------------------
City | LIBBY
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59923-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-293-0100
-----------------------------------------------------
Fax | 406-293-2453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF NURSING
-----------------------------------------------------
Name | CATHY WOLFE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-293-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 10882
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------