1255524674 NPI number — FRONTIER WYOMING, L.L.C.

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 1255524674 NPI number — FRONTIER WYOMING, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRONTIER WYOMING, L.L.C.
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:
1255524674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2017
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:
907 N POPLAR ST
Provider Second Line Business Practice Location Address:
SUITE 277
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-1320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-234-6684
Provider Business Practice Location Address Fax Number:
307-234-6066
Provider Enumeration Date:
08/20/2007

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: "Y" .

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

  • Identifier: 1255524674 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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