Provider Demographics
NPI:1104597939
Name:TRIPLE DIVIDE LODGE LLC
Entity type:Organization
Organization Name:TRIPLE DIVIDE LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-296-4272
Mailing Address - Street 1:200 HUBBART DAM RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MT
Mailing Address - Zip Code:59925-9708
Mailing Address - Country:US
Mailing Address - Phone:406-296-4272
Mailing Address - Fax:406-854-2835
Practice Address - Street 1:200 HUBBART DAM RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MT
Practice Address - Zip Code:59925-9708
Practice Address - Country:US
Practice Address - Phone:406-296-4272
Practice Address - Fax:406-854-2835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder