Provider Demographics
NPI:1043436983
Name:COMMUNITY ACTION OF LARAMIE COUNTY
Entity Type:Organization
Organization Name:COMMUNITY ACTION OF LARAMIE COUNTY
Other - Org Name:CROSSROADS HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IPSER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:307-632-8064
Mailing Address - Street 1:100 CENTRAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1330
Mailing Address - Country:US
Mailing Address - Phone:307-632-8064
Mailing Address - Fax:307-632-6131
Practice Address - Street 1:100 CENTRAL AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-1330
Practice Address - Country:US
Practice Address - Phone:307-632-8064
Practice Address - Fax:307-632-6131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY20234.0234261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)