Basic Information
Provider Information | |||||||||
NPI: | 1699765552 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOGAN HEALTH - CONRAD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LOGAN HEALTH HOME CARE - CONRAD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 758 | ||||||||
Address2: |   | ||||||||
City: | CONRAD | ||||||||
State: | MT | ||||||||
PostalCode: | 594250758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062713211 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 805 SUNSET BLVD | ||||||||
Address2: |   | ||||||||
City: | CONRAD | ||||||||
State: | MT | ||||||||
PostalCode: | 594251717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062713211 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2005 | ||||||||
LastUpdateDate: | 08/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ERICKSON | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CNO | ||||||||
AuthorizedOfficialTelephone: | 4062713211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/02/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 10050 | MT | Y |   | Agencies | Home Health |   |
No ID Information.