1336289297 NPI number — VASE FUNERAL HOME

Table of content: (NPI 1336289297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336289297 NPI number — VASE FUNERAL HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VASE FUNERAL HOME
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:
1336289297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK SPRINGS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82902-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-883-4336
Provider Business Mailing Address Fax Number:
307-362-4339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 ELK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-362-5607
Provider Business Practice Location Address Fax Number:
307-362-2750
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VASE
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-362-5607

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  68 , 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: 112443900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04796001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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