Provider Demographics
NPI:1285854885
Name:CRYSTAL CREEK LODGE
Entity Type:Organization
Organization Name:CRYSTAL CREEK LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DURAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAR MEDICINE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-338-6330
Mailing Address - Street 1:OLD HOSPITAL ROAD #1
Mailing Address - Street 2:P.O. BOX 450
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417-0450
Mailing Address - Country:US
Mailing Address - Phone:406-338-6330
Mailing Address - Fax:406-338-7660
Practice Address - Street 1:OLD HOSPITAL ROAD #1
Practice Address - Street 2:
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417-0450
Practice Address - Country:US
Practice Address - Phone:406-338-6330
Practice Address - Fax:406-338-7660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10530324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility