1770692857 NPI number — SERVICES FOR SENIORS PROGRAM, INC

Table of content: (NPI 1770692857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770692857 NPI number — SERVICES FOR SENIORS PROGRAM, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVICES FOR SENIORS PROGRAM, INC
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:
SERVICES FOR SENIORS, INC
Provider Other Organization Name Type Code:
5
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:
1770692857
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEATLAND
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-322-3424
Provider Business Mailing Address Fax Number:
307-322-4625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 16TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEATLAND
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-322-3424
Provider Business Practice Location Address Fax Number:
307-322-4625
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENSEL
Authorized Official First Name:
DEANNE
Authorized Official Middle Name:
FAYE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
307-322-3424

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 111504900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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