Provider Demographics
NPI:1447386057
Name:CHEYENNE-LARAMIE COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:CHEYENNE-LARAMIE COUNTY HEALTH DEPARTMENT
Other - Org Name:CITY OF CHEYENNE-LARAMIE COUNTY HEALTH BOARD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-633-4011
Mailing Address - Street 1:100 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1330
Mailing Address - Country:US
Mailing Address - Phone:307-633-4098
Mailing Address - Fax:307-633-4066
Practice Address - Street 1:100 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-1330
Practice Address - Country:US
Practice Address - Phone:307-633-4098
Practice Address - Fax:307-633-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3923A251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY124188500Medicaid
WY124188502Medicaid
WY124188500Medicaid
WYPHS0000Medicare UPIN