Basic Information
| Provider Information | |||||||||
| NPI: | 1396786448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLARKS FORK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SO 2 ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGER | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590140486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066623740 | ||||||||
| FaxNumber: | 4066623469 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 S 2 ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGER | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066623740 | ||||||||
| FaxNumber: | 4066623469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAQUETTE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 4062373071 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 9717 | MT | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.