Provider Demographics
NPI:1700895752
Name:FALLON MEDICAL COMPLEX INC
Entity Type:Organization
Organization Name:FALLON MEDICAL COMPLEX INC
Other - Org Name:COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-778-5103
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:202 SOUTH 4TH STREET WEST
Mailing Address - City:BAKER
Mailing Address - State:MT
Mailing Address - Zip Code:59313-1119
Mailing Address - Country:US
Mailing Address - Phone:406-778-2833
Mailing Address - Fax:406-778-5155
Practice Address - Street 1:202 SOUTH 4TH STREET WEST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:MT
Practice Address - Zip Code:59313-1119
Practice Address - Country:US
Practice Address - Phone:406-778-2833
Practice Address - Fax:406-778-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT720369Medicaid
MT720369Medicaid