Provider Demographics
NPI:1639552235
Name:EAST LAKESIDE CLINIC
Entity Type:Organization
Organization Name:EAST LAKESIDE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:406-755-3751
Mailing Address - Street 1:7935 MT HWY 35 STE 201
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911
Mailing Address - Country:US
Mailing Address - Phone:406-837-4357
Mailing Address - Fax:
Practice Address - Street 1:7935 MT HIGHWAY 35 STE 201
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911-5711
Practice Address - Country:US
Practice Address - Phone:406-837-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKESIDE CLINIC P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10172261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care