Provider Demographics
NPI:1073537601
Name:CHEYENNE CHILDREN'S CLINIC, PC
Entity Type:Organization
Organization Name:CHEYENNE CHILDREN'S CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:THEOBALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-635-7961
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3176
Mailing Address - Country:US
Mailing Address - Phone:307-635-7961
Mailing Address - Fax:307-778-5812
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-635-7961
Practice Address - Fax:307-778-5812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty