Provider Demographics
NPI:1073781548
Name:GREAT FALLS CLINIC
Entity Type:Organization
Organization Name:GREAT FALLS CLINIC
Other - Org Name:CHOTEAU CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SINCLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-454-2171
Mailing Address - Street 1:1400 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5353
Mailing Address - Country:US
Mailing Address - Phone:406-454-2141
Mailing Address - Fax:406-771-3021
Practice Address - Street 1:124 MAIN AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:CHOTEAU
Practice Address - State:MT
Practice Address - Zip Code:59422-9410
Practice Address - Country:US
Practice Address - Phone:406-466-5255
Practice Address - Fax:406-466-5256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT FALLS CLINIC, LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-18
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0720341Medicaid
MT0720341Medicaid