Provider Demographics
NPI: | 1285193060 |
---|---|
Name: | WIND RIVER FAMILY & COMMUNITY HEALTH CARE |
Entity Type: | Organization |
Organization Name: | WIND RIVER FAMILY & COMMUNITY HEALTH CARE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING |
Authorized Official - Prefix: | |
Authorized Official - First Name: | TILINA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ROBINSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 307-857-9486 |
Mailing Address - Street 1: | PO BOX 1310 |
Mailing Address - Street 2: | |
Mailing Address - City: | RIVERTON |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 82501-0158 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 307-856-9281 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 511 N 12TH ST E |
Practice Address - Street 2: | |
Practice Address - City: | RIVERTON |
Practice Address - State: | WY |
Practice Address - Zip Code: | 82501-3809 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-463-4488 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | WIND RIVER FAMILY & COMMUNITY HEALTH CARE |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2019-03-19 |
Last Update Date: | 2020-01-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |