Provider Demographics
NPI:1962566034
Name:ROOSEVELT COUNTY
Entity type:Organization
Organization Name:ROOSEVELT COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMMISSIONER - CHAIR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-653-6248
Mailing Address - Street 1:124 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:WOLF POINT
Mailing Address - State:MT
Mailing Address - Zip Code:59201-1640
Mailing Address - Country:US
Mailing Address - Phone:406-653-6223
Mailing Address - Fax:406-653-6210
Practice Address - Street 1:124 CUSTER ST
Practice Address - Street 2:
Practice Address - City:WOLF POINT
Practice Address - State:MT
Practice Address - Zip Code:59201-1640
Practice Address - Country:US
Practice Address - Phone:406-653-6223
Practice Address - Fax:406-653-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000352950Medicaid
MT0000352950Medicaid
MT00000-3383Medicare ID - Type UnspecifiedROSTER BILLING