Provider Demographics
NPI:1740980291
Name:WHITE BUFFALO HEALING LODGE
Entity type:Organization
Organization Name:WHITE BUFFALO HEALING LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSTON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:406-221-7058
Mailing Address - Street 1:22 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1714
Mailing Address - Country:US
Mailing Address - Phone:406-221-7058
Mailing Address - Fax:
Practice Address - Street 1:22 W PARK ST # 211
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1714
Practice Address - Country:US
Practice Address - Phone:406-221-7058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty