Provider Demographics
NPI:1477509651
Name:INDEPENDENT FAMILY PRACTICE
Entity Type:Organization
Organization Name:INDEPENDENT FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-883-4437
Mailing Address - Street 1:122 PETERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127
Mailing Address - Country:US
Mailing Address - Phone:307-883-4437
Mailing Address - Fax:307-883-4436
Practice Address - Street 1:122 PETERSON PKWY
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-4437
Practice Address - Fax:307-883-4436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty