1508979535 NPI number — ROCKY MOUNTAIN SPORTS MEDICINE AND REHABILITATION LLC

Table of content: (NPI 1508979535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508979535 NPI number — ROCKY MOUNTAIN SPORTS MEDICINE AND REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROCKY MOUNTAIN SPORTS MEDICINE AND REHABILITATION LLC
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1508979535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 GATEWAY BLVD UNIT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82901-6727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-352-3626
Provider Business Mailing Address Fax Number:
307-352-3628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 GATEWAY BLVD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-6786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-352-3626
Provider Business Practice Location Address Fax Number:
307-352-3628
Provider Enumeration Date:
08/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KNUDSON
Authorized Official First Name:
JAELYN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
307-352-3626

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 118547100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".