Provider Demographics
NPI:1184640104
Name:BOHANNON CREEK ENTERPRISES, INC.
Entity Type:Organization
Organization Name:BOHANNON CREEK ENTERPRISES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:H
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:503-372-2740
Mailing Address - Street 1:PO BOX 34940
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1940
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2754
Practice Address - Street 1:90 HIGHWAY 91 SOUTH
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3516
Practice Address - Country:US
Practice Address - Phone:406-683-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4302037Medicaid