Provider Demographics
NPI:1588853162
Name:HOWARD MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:HOWARD MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:H
Authorized Official - Last Name:THEDIECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-745-4884
Mailing Address - Street 1:3810 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5179
Mailing Address - Country:US
Mailing Address - Phone:307-745-4884
Mailing Address - Fax:
Practice Address - Street 1:3810 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5179
Practice Address - Country:US
Practice Address - Phone:307-745-4884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6716A261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service