1053432336 NPI number — SSC CHEYENNE OPERATING COMPANY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053432336 NPI number — SSC CHEYENNE OPERATING COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSC CHEYENNE OPERATING COMPANY 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:
6
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:
1053432336
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 W SAM HOUSTON PKWY N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77041-5161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-467-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001-5604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-634-7986
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIMONS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
SENIOR VP OPERATIONS FINANCE
Authorized Official Telephone Number:
770-829-5100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  07063 , 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)

  • Identifier: 120858600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0107449100WY . This is a "PREVIOUS MEDICAID NUMBER" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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