Provider Demographics
NPI:1205875978
Name:LAKESIDE QRU, INC
Entity type:Organization
Organization Name:LAKESIDE QRU, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-844-2775
Mailing Address - Street 1:PO BOX 2458
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MT
Mailing Address - Zip Code:59917-2458
Mailing Address - Country:US
Mailing Address - Phone:406-297-1627
Mailing Address - Fax:406-297-4144
Practice Address - Street 1:201 BILLS RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922
Practice Address - Country:US
Practice Address - Phone:406-844-2775
Practice Address - Fax:406-844-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1523416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT657682OtherBC BS
MT65762OtherBLUE CROSS BLUE SHIELD
MT0442238Medicaid
000020010Medicare PIN
MT000020010Medicare Oscar/Certification
MT657682OtherBC BS