Basic Information
| Provider Information | |||||||||
| NPI: | 1659743441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOGAN HEALTH CARE CENTER - SHELBY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MARIAS CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 310 SUNNYVIEW LN | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067525111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 630 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594741663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064343260 | ||||||||
| FaxNumber: | 4064343274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2015 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4067521724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KALISPELL REGIONAL HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.