Provider Demographics
NPI:1306883905
Name:LOLO FAMILY PRACTICE INC
Entity type:Organization
Organization Name:LOLO FAMILY PRACTICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIR OF ANCILLARY & SATELLITE SRVCS
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-721-5600
Mailing Address - Street 1:PO BOX 7638
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11350 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-9689
Practice Address - Country:US
Practice Address - Phone:406-273-0045
Practice Address - Fax:406-327-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT290103T00000X
MT315363A00000X
MT5353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000081605Medicare ID - Type Unspecified