Provider Demographics
NPI:1649279183
Name:IMMANUEL LUTHERAN CORPORATION
Entity type:Organization
Organization Name:IMMANUEL LUTHERAN CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR.CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA CEO,CALA, FELLO
Authorized Official - Phone:406-752-9622
Mailing Address - Street 1:185 CRESTLINE AVE
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3573
Mailing Address - Country:US
Mailing Address - Phone:406-752-9622
Mailing Address - Fax:406-752-9615
Practice Address - Street 1:185 CRESTLINE AVE
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3573
Practice Address - Country:US
Practice Address - Phone:406-752-9622
Practice Address - Fax:406-752-9615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10077314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0534430Medicaid
MT40632OtherBCBS
MT0348023Medicaid
MT0313300Medicaid
MT0347815Medicaid
MT0313300Medicaid