Provider Demographics
NPI:1497753115
Name:POWELL VALLEY HEALTH CARE INC
Entity Type:Organization
Organization Name:POWELL VALLEY HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-754-1107
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2260
Mailing Address - Country:US
Mailing Address - Phone:307-754-2267
Mailing Address - Fax:307-754-3176
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-754-1101
Practice Address - Fax:307-754-3176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07084282NC0060X
WY10207282NR1301X
WY0653416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No282NR1301XHospitalsGeneral Acute Care HospitalRural
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107185807Medicaid
WY007203OtherBCBS PROVIDER NUMBER
WY107185805Medicaid
WY107185800Medicaid
WY107185809Medicaid
WY107185800Medicaid
WY107185800Medicaid