Provider Demographics
NPI:1285769786
Name:MISSOULA URBAN INDIAN HEALTH CENTER, INC.
Entity type:Organization
Organization Name:MISSOULA URBAN INDIAN HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUISED HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:406-829-9515
Mailing Address - Street 1:830 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7931
Mailing Address - Country:US
Mailing Address - Phone:406-829-9515
Mailing Address - Fax:406-829-9519
Practice Address - Street 1:830 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7931
Practice Address - Country:US
Practice Address - Phone:406-829-9515
Practice Address - Fax:406-829-9519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT224-15261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0320025Medicaid