Basic Information
| Provider Information | |||||||||
| NPI: | 1366582686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKY MOUNTAIN HOME CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2110 OVERLAND AVE STE 114 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591026440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066528883 | ||||||||
| FaxNumber: | 4066528879 | ||||||||
| Practice Location | |||||||||
| Address1: | 2110 OVERLAND AVE STE 114 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591026440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066528883 | ||||||||
| FaxNumber: | 4066528879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 09/04/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PECK | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESSIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4066528883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 10570 | MT | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 746701 | 05 | MT | MEDICAID | 380198 | 05 | MT | MEDICAID | 620330 | 05 | MT | MEDICAID |