Provider Demographics
NPI:1225045370
Name:RAVALLI COUNTY
Entity type:Organization
Organization Name:RAVALLI COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP/C
Authorized Official - Phone:406-375-6670
Mailing Address - Street 1:205 BEDFORD ST
Mailing Address - Street 2:SUITE L
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2853
Mailing Address - Country:US
Mailing Address - Phone:406-375-6670
Mailing Address - Fax:406-375-6680
Practice Address - Street 1:205 BEDFORD ST
Practice Address - Street 2:SUITE L
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2853
Practice Address - Country:US
Practice Address - Phone:406-375-6670
Practice Address - Fax:406-375-6680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAVALLI COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-02
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMS0194958251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT350-0952Medicaid
MT13561OtherBLUE CROSS BLUE SHIELD
MT31388OtherBCBS IZ'S
MT31388OtherBLUE CHIP
MT94450094OtherMBCHP
MT31388OtherBCBS IZ'S