Provider Demographics
NPI:1245312644
Name:FOUR CORNERS HEALTH CARE INC
Entity type:Organization
Organization Name:FOUR CORNERS HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT HEALTH CARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:SILLS
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:CNP PNP FNP
Authorized Official - Phone:406-556-8300
Mailing Address - Street 1:7720 SHEDHORN DR STE D
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:406-556-8300
Mailing Address - Fax:406-556-8304
Practice Address - Street 1:7720 SHEDHORN DR STE D
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-556-8300
Practice Address - Fax:406-556-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN20521363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307043Medicaid
MT4307043Medicaid