Provider Demographics
NPI:1962904219
Name:SOMER R MAZZUCOLA LLC
Entity type:Organization
Organization Name:SOMER R MAZZUCOLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOMER
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAZZUCOLA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, ANCC-BC
Authorized Official - Phone:931-241-0429
Mailing Address - Street 1:1495 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-7325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3856
Practice Address - Country:US
Practice Address - Phone:406-443-7733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care