Basic Information
Provider Information | |||||||||
NPI: | 1306883905 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOLO FAMILY PRACTICE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LOLO FLORENCE FAMILY PRACTICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7638 | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598077638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11350 US HIGHWAY 93 S | ||||||||
Address2: |   | ||||||||
City: | LOLO | ||||||||
State: | MT | ||||||||
PostalCode: | 598479689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062730045 | ||||||||
FaxNumber: | 4063273065 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 05/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STEVENS | ||||||||
AuthorizedOfficialFirstName: | JOYCE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | DIR OF ANCILLARY & SATELLITE SRVCS | ||||||||
AuthorizedOfficialTelephone: | 4067215600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 290 | MT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 363A00000X | 315 | MT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 207Q00000X | 5353 | MT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.