Provider Demographics
NPI:1700942455
Name:BOZEMAN DIALYSIS CENTER
Entity Type:Organization
Organization Name:BOZEMAN DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-585-1077
Mailing Address - Street 1:931 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 3105
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6911
Mailing Address - Country:US
Mailing Address - Phone:406-585-5090
Mailing Address - Fax:406-585-1070
Practice Address - Street 1:931 HIGHLAND BLVD
Practice Address - Street 2:SUITE 3105
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6911
Practice Address - Country:US
Practice Address - Phone:406-585-5090
Practice Address - Fax:406-585-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0730218OtherMDCD PIN
MT272503Medicare Oscar/Certification