Provider Demographics
NPI:1063459501
Name:1130 SEVENTEENTH AVENUE OPERATIONS LLC
Entity Type:Organization
Organization Name:1130 SEVENTEENTH AVENUE OPERATIONS LLC
Other - Org Name:MISSOURI RIVER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:1130 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4523
Mailing Address - Country:US
Mailing Address - Phone:406-771-4500
Mailing Address - Fax:
Practice Address - Street 1:1130 17TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4523
Practice Address - Country:US
Practice Address - Phone:406-771-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12680314000000X
MT9207314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3400982Medicaid
MT0534548Medicaid
MT310301Medicaid
MT3400969Medicaid
MT41502OtherBC/BS
MT3400969Medicaid