Basic Information
| Provider Information | |||||||||
| NPI: | 1265425854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOGAN HEALTH - CONRAD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOGAN HEALTH - CONRAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 805 SUNSET BLVD | ||||||||
| Address2: | P O BOX 758 | ||||||||
| City: | CONRAD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594251717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062713211 | ||||||||
| FaxNumber: | 4062713917 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | CONRAD | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594251717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062713211 | ||||||||
| FaxNumber: | 4062713917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CNO | ||||||||
| AuthorizedOfficialTelephone: | 4062713211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KALISPELL REGIONAL HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 9650 | MT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 40292 | 01 | MT | BCBS OF MT | OTHER | 0310232 | 05 | MT | MEDICAID |