Provider Demographics
NPI:1326217340
Name:MASONIC HOME OF MONTANA, INC.
Entity type:Organization
Organization Name:MASONIC HOME OF MONTANA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-458-5431
Mailing Address - Street 1:2010 MASONIC HOME RD
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-9517
Mailing Address - Country:US
Mailing Address - Phone:406-458-5461
Mailing Address - Fax:
Practice Address - Street 1:2010 MASONIC HOME RD
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-9517
Practice Address - Country:US
Practice Address - Phone:406-458-5461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-24
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10266310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0650522Medicaid