Provider Demographics
NPI:1619096369
Name:PRICKLY PEAR COOP - CLANCY
Entity Type:Organization
Organization Name:PRICKLY PEAR COOP - CLANCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VAUGHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-227-7322
Mailing Address - Street 1:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:EAST HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59635-1280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 CLANCY CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CLANCY
Practice Address - State:MT
Practice Address - Zip Code:59634-0000
Practice Address - Country:US
Practice Address - Phone:406-933-5531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT165172Medicaid