Provider Demographics
NPI:1043229776
Name:FALLON MEDICAL COMPLEX INC
Entity Type:Organization
Organization Name:FALLON MEDICAL COMPLEX INC
Other - Org Name:WIBAUX CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-778-5103
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:202 SOUTH 4TH STREET WEST
Mailing Address - City:BAKER
Mailing Address - State:MT
Mailing Address - Zip Code:59313-1119
Mailing Address - Country:US
Mailing Address - Phone:406-778-2833
Mailing Address - Fax:406-778-5155
Practice Address - Street 1:710 DRAKE STREET
Practice Address - Street 2:
Practice Address - City:WIBAUX
Practice Address - State:MT
Practice Address - Zip Code:59353
Practice Address - Country:US
Practice Address - Phone:406-778-2833
Practice Address - Fax:406-778-5155
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FALLON MEDICAL COMPLEX INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000008440Medicare PIN