Provider Demographics
NPI:1063005940
Name:WELLNESS WAGON
Entity Type:Organization
Organization Name:WELLNESS WAGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOXBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:970-371-9038
Mailing Address - Street 1:PO BOX 2417
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-2417
Mailing Address - Country:US
Mailing Address - Phone:307-638-0300
Mailing Address - Fax:307-658-0394
Practice Address - Street 1:208 MAIN ST #12
Practice Address - Street 2:
Practice Address - City:LINGLE
Practice Address - State:WY
Practice Address - Zip Code:82223
Practice Address - Country:US
Practice Address - Phone:970-371-9038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center