Provider Demographics
NPI:1366634396
Name:WYOMING WIC PROGRAM
Entity Type:Organization
Organization Name:WYOMING WIC PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SPECIALIST 3
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-777-7494
Mailing Address - Street 1:6101 YELLOWSTONE ROAD
Mailing Address - Street 2:SUITE 510
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82002-0001
Mailing Address - Country:US
Mailing Address - Phone:307-777-7494
Mailing Address - Fax:307-777-5643
Practice Address - Street 1:6101 YELLOWSTONE ROAD
Practice Address - Street 2:SUITE 510
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82002-0001
Practice Address - Country:US
Practice Address - Phone:307-777-7494
Practice Address - Fax:307-777-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1366634396Medicaid