Provider Demographics
NPI:1710221296
Name:HUCKLEBERRY HEALTHCARE INC
Entity Type:Organization
Organization Name:HUCKLEBERRY HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:406-315-3503
Mailing Address - Street 1:PO BOX 6191
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6191
Mailing Address - Country:US
Mailing Address - Phone:406-315-3503
Mailing Address - Fax:406-315-3505
Practice Address - Street 1:2517 7TH AVE S
Practice Address - Street 2:B-3
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-3032
Practice Address - Country:US
Practice Address - Phone:406-315-3503
Practice Address - Fax:406-315-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT019237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty