1194056127 NPI number — WAMSUTTER COMMUNITY HEALTH CENTER26-

Table of content: (NPI 1194056127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194056127 NPI number — WAMSUTTER COMMUNITY HEALTH CENTER26-

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAMSUTTER COMMUNITY HEALTH CENTER26-
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194056127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAMSUTTER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-328-0468
Provider Business Mailing Address Fax Number:
307-324-9438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 FULTZ DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAMSUTTER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-328-0468
Provider Business Practice Location Address Fax Number:
307-324-9438
Provider Enumeration Date:
01/14/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COUCH II
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
307-324-6002

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  5629A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 279 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)