Provider Demographics
NPI:1861511669
Name:ANACONDA DEER LODGE CO FAMILY PLANNING
Entity Type:Organization
Organization Name:ANACONDA DEER LODGE CO FAMILY PLANNING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-497-5001
Mailing Address - Street 1:115 W COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-2246
Mailing Address - Country:US
Mailing Address - Phone:406-563-7863
Mailing Address - Fax:406-563-2387
Practice Address - Street 1:115 W COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2246
Practice Address - Country:US
Practice Address - Phone:406-563-7863
Practice Address - Fax:406-563-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN11730363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty