Provider Demographics
NPI:1750428520
Name:PROGRESSIVE PERSONAL CARE
Entity type:Organization
Organization Name:PROGRESSIVE PERSONAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-251-9333
Mailing Address - Street 1:1921 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6640
Mailing Address - Country:US
Mailing Address - Phone:406-251-9333
Mailing Address - Fax:406-543-6043
Practice Address - Street 1:1921 OXFORD ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6640
Practice Address - Country:US
Practice Address - Phone:406-251-9333
Practice Address - Fax:406-543-6043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK385H00000X
251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0470781Medicaid
AKPCG653Medicaid
MT0601443Medicaid