Provider Demographics
NPI:1649477647
Name:LYMPHEDEMA AND OCCUPATIONAL THERAPY SERVICE, INC
Entity type:Organization
Organization Name:LYMPHEDEMA AND OCCUPATIONAL THERAPY SERVICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OTR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MIKLOS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:406-752-0330
Mailing Address - Street 1:PO BOX 3033
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903
Mailing Address - Country:US
Mailing Address - Phone:406-752-0330
Mailing Address - Fax:
Practice Address - Street 1:80 FOUR MILE DR STE 14A
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2665
Practice Address - Country:US
Practice Address - Phone:406-752-0330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0349690Medicaid
MTDB3419OtherRAILROAD MEDICARE
MTDB3419OtherRAILROAD MEDICARE