Provider Demographics
NPI:1235770249
Name:WESTERN WYOMING MEDICAL LLC
Entity Type:Organization
Organization Name:WESTERN WYOMING MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-372-7510
Mailing Address - Street 1:1521 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-9776
Mailing Address - Country:US
Mailing Address - Phone:318-372-7510
Mailing Address - Fax:
Practice Address - Street 1:535 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3410
Practice Address - Country:US
Practice Address - Phone:318-372-7510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical