Provider Demographics
NPI:1598942138
Name:COAL COUNTRY CLINIC, LLC
Entity Type:Organization
Organization Name:COAL COUNTRY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINSEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:307-682-3004
Mailing Address - Street 1:1206 W 4TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3300
Mailing Address - Country:US
Mailing Address - Phone:307-682-3004
Mailing Address - Fax:307-682-3558
Practice Address - Street 1:1206 W 4TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3300
Practice Address - Country:US
Practice Address - Phone:307-682-3004
Practice Address - Fax:307-682-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730186255OtherNURSE PRACTITIONER
WYPENDINGOtherBLUE CROSS BLUE SHIELD
WYPENDINGMedicaid
1730186255OtherNURSE PRACTITIONER
WYPENDINGMedicare PIN