MEDICARE: HOSPICE OF MISSOULA LLC

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	251G00000X	Community Based Hospice Care Agency	9596	MT

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	350190	OTHER	MT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1437143484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOSPICE OF MISSOULA LLC

Provider Business Mailing Address
First Line	:	800 KENSINGTON AVE
Second Line	:	SUITE 209
City	:	MISSOULA
State	:	MT
Zip	:	59801-5674
Country	:	US
Telephone Number	:	406-543-4408
Fax Number	:	406-543-4418

Provider Business Practice Location Address
First Line	:	800 KENSINGTON AVE
Second Line	:	SUITE 209
City	:	MISSOULA
State	:	MT
Zip	:	59801-5674
Country	:	US
Telephone Number	:	406-543-4408
Fax Number	:	406-543-4418

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY JACKSON
Credential	:
Telephone Number	:	406-543-4408

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	08/22/2020

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