Provider Demographics
NPI:1841820669
Name:EXTRAORDINARY DISTANCES
Entity type:Organization
Organization Name:EXTRAORDINARY DISTANCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:H
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CBHPSS
Authorized Official - Phone:406-443-2455
Mailing Address - Street 1:178 W LYNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-2822
Mailing Address - Country:US
Mailing Address - Phone:406-443-2455
Mailing Address - Fax:
Practice Address - Street 1:178 W LYNDALE AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-2822
Practice Address - Country:US
Practice Address - Phone:406-443-2455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care