Provider Demographics
NPI:1598762965
Name:PAIN TREATMENT CENTER OF WYOMING, LLC
Entity Type:Organization
Organization Name:PAIN TREATMENT CENTER OF WYOMING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARLAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIBNIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-633-8100
Mailing Address - Street 1:PO BOX 20270
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7006
Mailing Address - Country:US
Mailing Address - Phone:307-633-8100
Mailing Address - Fax:307-633-8108
Practice Address - Street 1:903 S GREELEY HWY
Practice Address - Street 2:SUITE A
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-3057
Practice Address - Country:US
Practice Address - Phone:307-633-8100
Practice Address - Fax:307-633-8108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4305A208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY311983OtherBLUE CROSS BLUE SHIELD