Provider Demographics
NPI:1518983360
Name:SHAMROCK FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:SHAMROCK FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENNEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:ENP
Authorized Official - Phone:406-234-8863
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-0579
Mailing Address - Country:US
Mailing Address - Phone:406-234-3824
Mailing Address - Fax:406-234-1041
Practice Address - Street 1:2000 CLARK ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-2726
Practice Address - Country:US
Practice Address - Phone:406-234-3824
Practice Address - Fax:406-234-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4771207Q00000X
MTRN26836363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty