Provider Demographics
NPI:1427294792
Name:MAIN STREET CLINIC
Entity type:Organization
Organization Name:MAIN STREET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MENTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:406-570-1639
Mailing Address - Street 1:11 W MAIN ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-3700
Mailing Address - Country:US
Mailing Address - Phone:406-388-6151
Mailing Address - Fax:
Practice Address - Street 1:11 W MAIN ST
Practice Address - Street 2:SUITE 225
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3700
Practice Address - Country:US
Practice Address - Phone:406-388-6151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10584261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0079186Medicaid
MT0079186Medicaid