MEDICARE: FLATHEAD VALLEY CHEMICAL DEPENDENCY CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0000076391	OTHER	MT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1225106842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLATHEAD VALLEY CHEMICAL DEPENDENCY CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 7115
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59904-0115
Country	:	US
Telephone Number	:	406-756-6453
Fax Number	:	406-756-8546

Provider Business Practice Location Address
First Line	:	1312 N MERIDIAN RD
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59904-0115
Country	:	US
Telephone Number	:	406-756-6453
Fax Number	:	406-756-8546

Authorized Official
Title or Position	:	EXECTIVE DIRECTOR
Name	:	MICHAEL CUMMINS
Credential	:	MA
Telephone Number	:	406-756-6453

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	06/09/2011

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