Provider Demographics
NPI:1437659877
Name:MOUNTAIN LODGE LLC
Entity Type:Organization
Organization Name:MOUNTAIN LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RUDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-655-1883
Mailing Address - Street 1:1110 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2761
Mailing Address - Country:US
Mailing Address - Phone:307-358-1897
Mailing Address - Fax:
Practice Address - Street 1:1110 BIRCH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2761
Practice Address - Country:US
Practice Address - Phone:307-358-1897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility