1043453566 NPI number — FRONTIER WYOMING LLC

Table of content: LESLY MAGALI PORRAS EDUCATOR (NPI 1215103551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043453566 NPI number — FRONTIER WYOMING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRONTIER WYOMING 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:
1043453566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 RIVER ST
Provider Second Line Business Mailing Address:
YANKEE PROFESSIONAL BUILDING
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06460-3346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-693-3840
Provider Business Mailing Address Fax Number:
203-693-3841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 LARAMIE 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:
82001-2064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-634-5970
Provider Business Practice Location Address Fax Number:
307-634-5384
Provider Enumeration Date:
04/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BOGUCKI
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
203-693-3840

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 0713064 , 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: 1043453566 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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