Provider Demographics
NPI:1639374382
Name:CONVENIENCECARE CLINIC
Entity Type:Organization
Organization Name:CONVENIENCECARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYKAY
Authorized Official - Middle Name:
Authorized Official - Last Name:THURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:406-922-2750
Mailing Address - Street 1:2419 W MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3813
Mailing Address - Country:US
Mailing Address - Phone:406-922-2750
Mailing Address - Fax:406-922-2751
Practice Address - Street 1:2419 W MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3813
Practice Address - Country:US
Practice Address - Phone:406-922-2750
Practice Address - Fax:406-922-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN9447363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4308344Medicaid
MTQ65838Medicare UPIN
MT4308344Medicaid