1130 Seventeenth Avenue Operations LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

12680 Issued in MT

Legal business name

1130 SEVENTEENTH AVENUE OPERATIONS LLC

Doing business as

Missouri River Center

Practice address

1130 17TH Ave S
Great Falls, MT 59405-4523

Phone

(406) 771-4500

NPI assigned

Jun 1, 2006

Last updated

May 17, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael T. Berg

Title

Assistant Secretary

Phone

(505) 468-4752

Specialties & licenses 1

Addresses

Other identifiers 5

Other names 1

• Missouri River Center Doing business as

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Sunbridge Healthcare LLC

  dba Columbia Crest Center

  • Skilled Nursing Facility
  • Moses Lake, WA
  • NPI 1982651758

  Member Of

  NPD member

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149120000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1463443200000",
    "number": "1063459501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1130 17TH AVE S",
            "city": "GREAT FALLS",
            "state": "MT",
            "postal_code": "594054523",
            "telephone_number": "406-771-4500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1130 17TH AVE S",
            "city": "GREAT FALLS",
            "state": "MT",
            "postal_code": "594054523",
            "telephone_number": "406-771-4500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1130 SEVENTEENTH AVENUE OPERATIONS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-01",
        "last_updated": "2016-05-17",
        "status": "A",
        "authorized_official_last_name": "BERG",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "T.",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY",
        "authorized_official_telephone_number": "505-468-4752"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "MT",
            "license": "12680",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3400982",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0534548",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "310301",
            "state": "MT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3400969",
            "state": "MT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BC/BS",
            "identifier": "41502",
            "state": "MT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Missouri River Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 17, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.