Provider Demographics
NPI:1205369576
Name:ICBM INC
Entity Type:Organization
Organization Name:ICBM INC
Other - Org Name:ARC OF WYOMING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERNYAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-306-2737
Mailing Address - Street 1:126 ELK ST
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5241
Mailing Address - Country:US
Mailing Address - Phone:307-362-6029
Mailing Address - Fax:307-362-2379
Practice Address - Street 1:1501 RED TAIL DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5879
Practice Address - Country:US
Practice Address - Phone:307-362-6029
Practice Address - Fax:307-362-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility