Provider Demographics
NPI:1366501561
Name:WYOMING LIFE RESOURCE CENTER
Entity Type:Organization
Organization Name:WYOMING LIFE RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KULOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-335-6762
Mailing Address - Street 1:8204 STATE HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2941
Mailing Address - Country:US
Mailing Address - Phone:307-335-6700
Mailing Address - Fax:307-335-6764
Practice Address - Street 1:8204 STATE HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2941
Practice Address - Country:US
Practice Address - Phone:307-335-6700
Practice Address - Fax:307-335-6764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY100180900315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100180900Medicaid