Basic Information
| Provider Information | |||||||||
| NPI: | 1265597207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HILLSIDE HEALTH CARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523618000 | ||||||||
| FaxNumber: | 9523618060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598031137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062515100 | ||||||||
| FaxNumber: | 4062514278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEICHERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | 755 | MT | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 217598 | 05 | MT | MEDICAID | 2703785 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |