Provider Demographics
NPI:1124396601
Name:ANDREA M. ELLESTAD, LLC
Entity Type:Organization
Organization Name:ANDREA M. ELLESTAD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:406-203-6207
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847
Mailing Address - Country:US
Mailing Address - Phone:406-203-6207
Mailing Address - Fax:
Practice Address - Street 1:2831 FORT MISSOULA RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804
Practice Address - Country:US
Practice Address - Phone:406-203-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1098225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty