Provider Demographics
NPI:1831247782
Name:MISSION MOUNTAIN MEDICAL INC
Entity type:Organization
Organization Name:MISSION MOUNTAIN MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-883-2722
Mailing Address - Street 1:38889 DUBAY ROAD
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860
Mailing Address - Country:US
Mailing Address - Phone:406-883-2722
Mailing Address - Fax:406-883-0964
Practice Address - Street 1:38889 DUBAY ROAD
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860
Practice Address - Country:US
Practice Address - Phone:406-883-2722
Practice Address - Fax:406-883-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000810475Medicaid