Provider Demographics
NPI:1750410825
Name:GLACIER PROSTHETIC CARE, INC.
Entity type:Organization
Organization Name:GLACIER PROSTHETIC CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-755-3344
Mailing Address - Street 1:985 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3539
Mailing Address - Country:US
Mailing Address - Phone:406-755-3344
Mailing Address - Fax:406-755-2746
Practice Address - Street 1:205 VERMEER DR
Practice Address - Street 2:SUITE C
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-1660
Practice Address - Country:US
Practice Address - Phone:208-255-4106
Practice Address - Fax:208-255-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA385335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807555300Medicaid
ID807555300Medicaid