Basic Information
| Provider Information | |||||||||
| NPI: | 1700127040 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WYOMING MEDICAL CENTER CLINICAL LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE STE 160 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122702 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1233 E 2ND ST | ||||||||
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| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075777201 | ||||||||
| FaxNumber: | 3075777862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2013 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WYOMING MEDICAL CENTER, INC. | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 53D0519997 | WY | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.