Provider Demographics
NPI:1295319325
Name:POWDER RIVER COUNTY
Entity type:Organization
Organization Name:POWDER RIVER COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:VIKKI
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLEMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-436-2651
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:BROADUS
Mailing Address - State:MT
Mailing Address - Zip Code:59317-0489
Mailing Address - Country:US
Mailing Address - Phone:406-436-2651
Mailing Address - Fax:406-436-2652
Practice Address - Street 1:507 NORTH LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:BROADUS
Practice Address - State:MT
Practice Address - Zip Code:59317-0489
Practice Address - Country:US
Practice Address - Phone:406-436-2651
Practice Address - Fax:406-436-2652
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POWDER RIVER COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7171138Medicaid