Provider Demographics
NPI:1346389822
Name:MARY JEAN MEDINA
Entity Type:Organization
Organization Name:MARY JEAN MEDINA
Other - Org Name:ABILITIES UNLIMITED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-837-2155
Mailing Address - Street 1:PO BOX 363
Mailing Address - Street 2:
Mailing Address - City:LINGLE
Mailing Address - State:WY
Mailing Address - Zip Code:82223-0363
Mailing Address - Country:US
Mailing Address - Phone:307-837-2155
Mailing Address - Fax:978-285-0404
Practice Address - Street 1:221 MAIN ST.
Practice Address - Street 2:
Practice Address - City:LINGLE
Practice Address - State:WY
Practice Address - Zip Code:82223-0363
Practice Address - Country:US
Practice Address - Phone:307-837-2155
Practice Address - Fax:978-285-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118921200Medicaid