1881107175 NPI number — ERICA FARLEY OTRL

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 1881107175 NPI number — ERICA FARLEY OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARLEY
Provider First Name:
ERICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SERERINO
Provider Other First Name:
ERICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881107175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 W MAIN ST
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:
82501-3342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-857-7074
Provider Business Mailing Address Fax Number:
307-856-6459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1507 STILLWATER AVE STE A
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:
82009-7358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-514-9999
Provider Business Practice Location Address Fax Number:
307-514-6006
Provider Enumeration Date:
11/09/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OTR-1304 , 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)