Basic Information
| Provider Information | |||||||||
| NPI: | 1073080461 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSOULA COMMUNITY HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MINERAL COMMUNITY HOSPITAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598720066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068224841 | ||||||||
| FaxNumber: | 4068224963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1208 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598729667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068224841 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2018 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONROW-VERVERIS | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4068224841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.