=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942582234
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKY BOY HEALTH CENTER LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2011
-----------------------------------------------------
Last Update Date | 09/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 535 CLINIC RD E
-----------------------------------------------------
City | BOX ELDER
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59521-8826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-395-4486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 535 CLINIC RD E
-----------------------------------------------------
City | BOX ELDER
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59521-8826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LABORATORY SUPERVISOR
-----------------------------------------------------
Name | KAREN MYERS
-----------------------------------------------------
Credential | MT(ASCP)
-----------------------------------------------------
Telephone | 406-395-4486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 27D0701672
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------