Basic Information
| Provider Information | |||||||||
| NPI: | 1932422375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WIND RIVER HEALTH SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DUBOIS MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 N. 12TH ST E | ||||||||
| Address2: | WIND RIVER HEALTH SYSTEMS, INC. | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078576685 | ||||||||
| FaxNumber: | 3078579927 | ||||||||
| Practice Location | |||||||||
| Address1: | 5647 US HWY 26 | ||||||||
| Address2: | DUBOIS MEDICAL CLINIC | ||||||||
| City: | DUBOIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825133809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074552516 | ||||||||
| FaxNumber: | 3074552526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSEN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | KAREN | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS DEVELOPMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3078576685 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.