Provider Demographics
NPI:1194027953
Name:REGIONAL WEST MEDICAL CENTER
Entity Type:Organization
Organization Name:REGIONAL WEST MEDICAL CENTER
Other - Org Name:REGIONAL WEST LABORATORY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT / CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:F
Authorized Official - Last Name:ICKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-635-3711
Mailing Address - Street 1:4021 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4602
Mailing Address - Country:US
Mailing Address - Phone:308-630-1111
Mailing Address - Fax:308-630-1815
Practice Address - Street 1:1331 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4867
Practice Address - Country:US
Practice Address - Phone:307-638-7800
Practice Address - Fax:307-638-7805
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGIONAL WEST MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-30
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW24745Medicare PIN