Provider Demographics
NPI:1689098253
Name:IRVINE, KENTON
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:
Last Name:IRVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W FAGIN ST
Mailing Address - Street 2:PO BOX 160
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729-8923
Mailing Address - Country:US
Mailing Address - Phone:406-539-7133
Mailing Address - Fax:
Practice Address - Street 1:200 W FAGIN ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729-8923
Practice Address - Country:US
Practice Address - Phone:406-539-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12601310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility