Provider Demographics
NPI:1396842308
Name:LANDER VALLEY MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:LANDER VALLEY MEDICAL CENTER LLC
Other - Org Name:LANDER REGIONAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BIVACCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4536
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8913
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-332-4420
Practice Address - Fax:307-332-3548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06149282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00371001OtherBCBS PROFESSIONAL FEES
WY041434OtherBCBS
WY115864303Medicaid
WY115864300Medicaid
WY115864305Medicaid
WY115864304Medicaid
WA530010AMedicare Oscar/Certification