1346700622 NPI number — WIND RIVER FAMILY & COMMUNITY HEALTH CARE

Table of content: (NPI 1346700622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346700622 NPI number — WIND RIVER FAMILY & COMMUNITY HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WIND RIVER FAMILY & COMMUNITY HEALTH CARE
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:
1346700622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82501-0158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-856-9281
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 BLUE SKY HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ETHETE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-855-2751
Provider Business Practice Location Address Fax Number:
307-335-1038
Provider Enumeration Date:
03/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MINICK
Authorized Official First Name:
KERRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS ADMINISTRATOR
Authorized Official Telephone Number:
307-856-9281

Provider Taxonomy Codes

  • Taxonomy code: 332800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 154097100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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