Provider Demographics
NPI:1104854710
Name:WMC CLINIC
Entity Type:Organization
Organization Name:WMC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-4127
Practice Address - Country:US
Practice Address - Phone:307-347-2555
Practice Address - Fax:307-347-2597
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-30
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118243900Medicaid
WY118243900Medicaid