1619413044 NPI number — POWDER RIVER PHYSICAL MEDICINE & REHABILITATION, LLC

Table of content: (NPI 1619413044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619413044 NPI number — POWDER RIVER PHYSICAL MEDICINE & REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POWDER RIVER PHYSICAL MEDICINE & REHABILITATION, 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:
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:
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NPI Number Information

NPI Number:
1619413044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 W LAKEWAY RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
GILLETTE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82718-6372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-206-4990
Provider Business Mailing Address Fax Number:
307-363-4033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 W LAKEWAY RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
GILLETTE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82718-6372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-206-4990
Provider Business Practice Location Address Fax Number:
307-363-4033
Provider Enumeration Date:
01/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WALBY
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
307-206-4990

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  10678A , 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)





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