Provider Demographics
NPI:1689894800
Name:FALLON MEDICAL COMPLEX INC
Entity Type:Organization
Organization Name:FALLON MEDICAL COMPLEX INC
Other - Org Name:DME
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-778-5103
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:MT
Mailing Address - Zip Code:59313-0820
Mailing Address - Country:US
Mailing Address - Phone:406-778-5103
Mailing Address - Fax:406-778-5155
Practice Address - Street 1:202 SOUTH 4TH STREET WEST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:MT
Practice Address - Zip Code:59313-0820
Practice Address - Country:US
Practice Address - Phone:406-778-3331
Practice Address - Fax:406-778-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5605834Medicaid
MT5605834Medicaid