Provider Demographics
NPI:1528079720
Name:STATE OF MONTANA
Entity type:Organization
Organization Name:STATE OF MONTANA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEDDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-444-4497
Mailing Address - Street 1:111 N SANDERS ST RM 105
Mailing Address - Street 2:P O BOX 6429
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4520
Mailing Address - Country:US
Mailing Address - Phone:406-444-4497
Mailing Address - Fax:406-444-3082
Practice Address - Street 1:800 CASINO CREEK DR
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-3359
Practice Address - Country:US
Practice Address - Phone:406-538-7451
Practice Address - Fax:406-538-2863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10746310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT57-0414Medicaid
MT57-2546Medicaid
MT57-0197Medicaid
MT57-2676Medicaid
MT57-2676Medicaid
MT57-0197Medicaid
MT000003385Medicare PIN