Basic Information
| Provider Information | |||||||||
| NPI: | 1235238718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTTE SILVER BOW PRIMARY HEALTH CARE CLINIC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLACKTAIL DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 41 BARRETT ST | ||||||||
| Address2: | |||||||||
| City: | DILLON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597253508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066834440 | ||||||||
| FaxNumber: | 4066831121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| 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. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | MT | N | Ambulatory Health Care Facilities | Clinic/Center | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | MT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CK5130 | 01 | MT | RAILROAD MEDICARE | OTHER | 0730028 | 05 | MT | MEDICAID | 63392 | 01 | MT | BCBS | OTHER | 95601016 | 01 | MT | MT BREAST & CERVICAL PROG | OTHER |