Provider Demographics
NPI:1437143484
Name:HOSPICE OF MISSOULA LLC
Entity Type:Organization
Organization Name:HOSPICE OF MISSOULA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-543-4408
Mailing Address - Street 1:800 KENSINGTON AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5674
Mailing Address - Country:US
Mailing Address - Phone:406-543-4408
Mailing Address - Fax:406-543-4418
Practice Address - Street 1:800 KENSINGTON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5674
Practice Address - Country:US
Practice Address - Phone:406-543-4408
Practice Address - Fax:406-543-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9596251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0750210Medicaid
MT350190OtherBLUE CROSS BLUE SHIELD
MT0750210Medicaid