Provider Demographics
NPI:1972476257
Name:LDYBOSS LLC
Entity type:Organization
Organization Name:LDYBOSS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-781-4827
Mailing Address - Street 1:1009 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-1507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1009 3RD AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-1507
Practice Address - Country:US
Practice Address - Phone:406-781-4827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1616496OtherAPI
MT1616496Medicaid