Basic Information
| Provider Information | |||||||||
| NPI: | 1376702886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PONDEROSA PINES HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1341 ROSEBUD LN | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591016527 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1341 ROSEBUD LN | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591016527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062526135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | HANAWALT | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4062526135 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH MANAGEMENT SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 436 | MT | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 27-5096 | 01 | MT | MEDICARE PROVIDER NUMBER | OTHER |