Basic Information
| Provider Information | |||||||||
| NPI: | 1710927033 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEAK MEDICAL MONTANA OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | VALLEY VIEW CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 EAST HOLLY | ||||||||
| Address2: | |||||||||
| City: | SARATOGA | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073268212 | ||||||||
| FaxNumber: | 3073269611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROTHWELL | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05088 | WY | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 113698400 | 05 | WY | MEDICAID |