Provider Demographics
NPI:1558699835
Name:SOUTHWEST WYOMING REHABILITATION CENTER
Entity Type:Organization
Organization Name:SOUTHWEST WYOMING REHABILITATION CENTER
Other - Org Name:SWRC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-371-1241
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82902-0519
Mailing Address - Country:US
Mailing Address - Phone:307-371-1241
Mailing Address - Fax:307-362-4615
Practice Address - Street 1:4509 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4367
Practice Address - Country:US
Practice Address - Phone:307-371-1241
Practice Address - Fax:307-362-4615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services