Provider Demographics
NPI:1467559310
Name:AVENUES PHYSICAL THERAPY INC PC
Entity Type:Organization
Organization Name:AVENUES PHYSICAL THERAPY INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALYNN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:307-634-0298
Mailing Address - Street 1:611 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4304
Mailing Address - Country:US
Mailing Address - Phone:307-634-0298
Mailing Address - Fax:307-634-0837
Practice Address - Street 1:611 W 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4304
Practice Address - Country:US
Practice Address - Phone:307-634-0298
Practice Address - Fax:307-634-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107090800Medicaid
WY107090800Medicaid