Provider Demographics
NPI:1164704029
Name:OXBOW CENTER
Entity Type:Organization
Organization Name:OXBOW CENTER
Other - Org Name:CLOUD PEAK COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-250-2369
Mailing Address - Street 1:401 S 23RD ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3725
Mailing Address - Country:US
Mailing Address - Phone:307-347-6165
Mailing Address - Fax:307-347-6166
Practice Address - Street 1:401 S 23RD ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3725
Practice Address - Country:US
Practice Address - Phone:307-347-6165
Practice Address - Fax:307-347-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106352908Medicaid