Basic Information
| Provider Information | |||||||||
| NPI: | 1659580975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF CUSTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CUSTER COUNTY HEALTH DEPARTMENT AND FAMILY PLANNING | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593012726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068743377 | ||||||||
| FaxNumber: | 4068743459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 CLARK ST | ||||||||
| Address2: | |||||||||
| City: | MILES CITY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 593012726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068743377 | ||||||||
| FaxNumber: | 4068743459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHARDS | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4068743377 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, BSN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | RN24294 | MT | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 3504956 | 05 | MT | MEDICAID |