Basic Information
| Provider Information | |||||||||
| NPI: | 1205308855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FREMONT COUNTY PEDIATRICS LANDER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 BLACKMORE RD | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826093345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3072336089 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 WYOMING ST | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073322185 | ||||||||
| FaxNumber: | 3073327799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2018 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MUNSELL | ||||||||
| AuthorizedOfficialFirstName: | TAMRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3072336092 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.