MEDICARE: DEER LODGE CARE HOLDINGS, 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1700351210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEER LODGE CARE HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	5200 N PALM AVE STE 107
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-2225
Country	:	US
Telephone Number	:	559-901-3147
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 TEXAS AVE
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1829
Country	:	US
Telephone Number	:	406-846-1655
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BRANDON DAVID BIGELOW
Credential	:
Telephone Number	:	559-901-3147

Provider Enumeration Date	:	10/11/2018
Last Update Date	:	10/11/2018

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