Provider Demographics
NPI:1578946471
Name:STRAWBERRY ROAN STABLE LIVING LLC
Entity Type:Organization
Organization Name:STRAWBERRY ROAN STABLE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:406-473-2206
Mailing Address - Street 1:109 HIGH STREET
Mailing Address - Street 2:BOX 87
Mailing Address - City:JUDITH GAP
Mailing Address - State:MT
Mailing Address - Zip Code:59453-5945
Mailing Address - Country:US
Mailing Address - Phone:406-473-2206
Mailing Address - Fax:406-473-2207
Practice Address - Street 1:109 HIGH ST
Practice Address - Street 2:BOX 87
Practice Address - City:JUDITH GAP
Practice Address - State:MT
Practice Address - Zip Code:59453-7701
Practice Address - Country:US
Practice Address - Phone:406-473-2206
Practice Address - Fax:406-473-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MT13378310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251S00000XAgenciesCommunity/Behavioral Health