Basic Information
| Provider Information | |||||||||
| NPI: | 1629543152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF CENTRAL WYOMING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 BLACKMORE RD | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826093345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 BLACKMORE RD | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826093345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2018 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3072336022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1152611-00 | 05 | WY | MEDICAID |