Provider Demographics
NPI:1326058207
Name:STATE OF MONTANA
Entity Type:Organization
Organization Name:STATE OF MONTANA
Other - Org Name:MONTANA DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FISCAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEDDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-444-4497
Mailing Address - Street 1:111 N SANDERS ST RM 105
Mailing Address - Street 2:P O BOX 6429
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4520
Mailing Address - Country:US
Mailing Address - Phone:406-444-4497
Mailing Address - Fax:406-444-3082
Practice Address - Street 1:310 FOURTH AVENUE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632-0087
Practice Address - Country:US
Practice Address - Phone:406-225-4410
Practice Address - Fax:406-225-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10867315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT57-0037Medicaid
MT57-0063Medicaid
MT57-0336Medicaid
MT57-2598Medicaid
MT57-0095Medicaid
MT57-0061Medicaid
MT57-0050Medicaid
MT000009910Medicare ID - Type UnspecifiedPSYCH & MED PROFESS
MT57-0037Medicaid
MT57-0061Medicaid