Basic Information
| Provider Information | |||||||||
| NPI: | 1821043621 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1100 TEXAS AVENUE OPERATIONS LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DEER LODGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597221829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068461655 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | DEER LODGE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597221829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4068461655 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEAK MEDICAL MONTANA OPERATIONS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 12681 | MT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0347718 | 05 | MT | MEDICAID | 0310250 | 05 | MT | MEDICAID | 0347701 | 05 | MT | MEDICAID |