Provider Demographics
NPI:1497127476
Name:TENDER HEART ASSISTED LIVING
Entity Type:Organization
Organization Name:TENDER HEART ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-444-8969
Mailing Address - Street 1:624 TWIN RIDGE AVE
Mailing Address - Street 2:PO BOX 2130
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5108
Mailing Address - Country:US
Mailing Address - Phone:307-444-8969
Mailing Address - Fax:307-789-8907
Practice Address - Street 1:624 TWIN RIDGE AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5108
Practice Address - Country:US
Practice Address - Phone:307-444-8969
Practice Address - Fax:307-789-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15018310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123782900Medicaid