Provider Demographics
NPI:1982659652
Name:MISSION VALLEY HEALTH CLINIC, INCORPORATED
Entity Type:Organization
Organization Name:MISSION VALLEY HEALTH CLINIC, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:CASTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-745-8765
Mailing Address - Street 1:35773 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-9001
Mailing Address - Country:US
Mailing Address - Phone:406-745-8765
Mailing Address - Fax:
Practice Address - Street 1:35773 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-9001
Practice Address - Country:US
Practice Address - Phone:406-745-8765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT145363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty