Provider Demographics
NPI:1609020254
Name:GRAND TETON HEALING CENTER INC
Entity Type:Organization
Organization Name:GRAND TETON HEALING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-949-1292
Mailing Address - Street 1:5008 WEDGEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401
Mailing Address - Country:US
Mailing Address - Phone:281-833-3330
Mailing Address - Fax:
Practice Address - Street 1:5715 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4322
Practice Address - Country:US
Practice Address - Phone:303-949-1292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-10
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL #1019261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation