Basic Information
| Provider Information | |||||||||
| NPI: | 1225502073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ANACONDA CHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 CENTENNIAL AVE | ||||||||
| Address2: | |||||||||
| City: | BUTTE | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597012870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067234075 | ||||||||
| FaxNumber: | 4064966035 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 OAK ST | ||||||||
| Address2: | |||||||||
| City: | ANACONDA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597112335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065630771 | ||||||||
| FaxNumber: | 4065630774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YATES | ||||||||
| AuthorizedOfficialFirstName: | SHAWNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4064966018 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.