Provider Demographics
NPI:1104032416
Name:URGENT CARE OF JACKSON HOLE, LLC
Entity Type:Organization
Organization Name:URGENT CARE OF JACKSON HOLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:MUSSER
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:307-739-8999
Mailing Address - Street 1:PO BOX 8640
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8640
Mailing Address - Country:US
Mailing Address - Phone:307-739-8999
Mailing Address - Fax:
Practice Address - Street 1:1415 SOUTH HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-739-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5551A207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1104032416Medicaid
WYC21112Medicare UPIN
WYW21373Medicare PIN