Provider Demographics
NPI:1225184989
Name:MEMORIAL HOSPITAL OF LARAMIE COUNTY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF LARAMIE COUNTY
Other - Org Name:COMMUNITY HOME CARE A SERVICE OF CHEYENNE REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-634-2273
Mailing Address - Street 1:627 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1530
Mailing Address - Country:US
Mailing Address - Phone:307-532-4180
Mailing Address - Fax:
Practice Address - Street 1:627 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1530
Practice Address - Country:US
Practice Address - Phone:307-532-4180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPITAL OF LARAMIE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07-218251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120485800Medicaid
WY120485801Medicaid
WY107334603Medicaid
WY537014Medicare Oscar/Certification