Provider Demographics
NPI:1003413212
Name:MEMORIAL HOSPITAL OF CONVERSE COUNTY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF CONVERSE COUNTY
Other - Org Name:LARAMIE PEAK RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUSSINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-358-2122
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1450
Mailing Address - Country:US
Mailing Address - Phone:307-358-1403
Mailing Address - Fax:307-358-3432
Practice Address - Street 1:1356 SHIEK ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-3231
Practice Address - Country:US
Practice Address - Phone:307-358-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF CONVERSE COUNT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-01
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health