1588688006 NPI number — STAR VALLEY MEDICAL

Table of content: (NPI 1588688006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588688006 NPI number — STAR VALLEY MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAR VALLEY MEDICAL
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:
STAR VALLEY HOME OXYGEN
Provider Other Organization Name Type Code:
3
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:
1588688006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83112-0156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-883-3445
Provider Business Mailing Address Fax Number:
307-883-3472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THAYNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83127-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-883-3445
Provider Business Practice Location Address Fax Number:
307-883-3472
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON-MILLER
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-883-3445

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114866400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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