Provider Demographics
NPI:1689264558
Name:COSTNER CARE FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:COSTNER CARE FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SIMEON
Authorized Official - Last Name:COSTNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP/APRN, NP-BC
Authorized Official - Phone:406-223-7966
Mailing Address - Street 1:406 W RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:MT
Mailing Address - Zip Code:59859-9597
Mailing Address - Country:US
Mailing Address - Phone:406-223-7966
Mailing Address - Fax:
Practice Address - Street 1:406 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:MT
Practice Address - Zip Code:59859-9597
Practice Address - Country:US
Practice Address - Phone:406-223-7966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty