Basic Information
| Provider Information | |||||||||
| NPI: | 1609811306 | ||||||||
| 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: | 9523618058 | ||||||||
| Practice Location | |||||||||
| Address1: | 4718 23RD AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598031163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062515100 | ||||||||
| FaxNumber: | 4062514278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| 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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 10323 | MT | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 0612482 | 05 | MT | MEDICAID | 840174 | 05 | MT | MEDICAID |