# 1130 SEVENTEENTH AVENUE OPERATIONS LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Missouri River Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063459501
- **Authorized official:** MICHAEL T. BERG (ASSISTANT SECRETARY)
- **Authorized official phone:** (505) 468-4752

## Contact information

- **Practice address:** 1130 17TH AVE S, GREAT FALLS, MT 59405-4523
- **Practice address phone:** (406) 771-4500
- **Mailing address:** 1130 17TH AVE S, GREAT FALLS, MT 59405-4523
- **Mailing address phone:** (406) 771-4500

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 12680 | MT | Yes |

## Other

- **Enumeration date:** 06/01/2006
- **Last updated:** 05/17/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0534548 | — | MT |
| 05 | — | 310301 | — | MT |
| 05 | — | 3400969 | — | MT |
| 05 | — | 3400982 | — | MT |
| 01 | — | 41502 | BC/BS | MT |