1073673042 NPI number — COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC

Table of content: (NPI 1073673042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073673042 NPI number — COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY HEALTH CENTER OF CENTRAL WYOMING 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:
COMMUNITY HEALTH CENTER OF CENTRAL WYOMING
Provider Other Organization Name Type Code:
3
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:
1073673042
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/25/2016
NPI Reactivation Date:
11/15/2016

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 BLACKMORE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82609-3345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-233-6050
Provider Business Mailing Address Fax Number:
307-233-6087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 BLACKMORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82609-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-233-6050
Provider Business Practice Location Address Fax Number:
307-233-6087
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DORNBIER
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST IN CHARGE
Authorized Official Telephone Number:
307-233-6050

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 5201621 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 115261101 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2111284 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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