Basic Information
Provider Information | |||||||||
NPI: | 1750428520 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROGRESSIVE PERSONAL CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1921 OXFORD ST | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598016640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062519333 | ||||||||
FaxNumber: | 4065436043 | ||||||||
Practice Location | |||||||||
Address1: | 1921 OXFORD ST | ||||||||
Address2: |   | ||||||||
City: | MISSOULA | ||||||||
State: | MT | ||||||||
PostalCode: | 598016640 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062519333 | ||||||||
FaxNumber: | 4065436043 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2007 | ||||||||
LastUpdateDate: | 01/21/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYNOLDS | ||||||||
AuthorizedOfficialFirstName: | KELLY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4062519333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X |   | AK | N |   | Respite Care Facility | Respite Care |   | 251X00000X |   |   | Y |   | Agencies | Supports Brokerage |   |
ID Information
ID | Type | State | Issuer | Description | 0470781 | 05 | MT |   | MEDICAID | PCG653 | 05 | AK |   | MEDICAID | 0601443 | 05 | MT |   | MEDICAID |