Provider Demographics
NPI: | 1619236791 |
---|---|
Name: | RIVERTON PHYSICIAN PRACTICES LLC |
Entity Type: | Organization |
Organization Name: | RIVERTON PHYSICIAN PRACTICES LLC |
Other - Org Name: | WIND RIVER ONCOLOGY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JESS |
Authorized Official - Middle Name: | N |
Authorized Official - Last Name: | JUDY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 615-372-8500 |
Mailing Address - Street 1: | 1005 COLLEGE VIEW DR |
Mailing Address - Street 2: | |
Mailing Address - City: | RIVERTON |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 82501-2289 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 307-857-5212 |
Mailing Address - Fax: | 307-857-5215 |
Practice Address - Street 1: | 2100 W SUNSET DR |
Practice Address - Street 2: | |
Practice Address - City: | RIVERTON |
Practice Address - State: | WY |
Practice Address - Zip Code: | 82501-2274 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-857-5286 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-05-10 |
Last Update Date: | 2012-05-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Single Specialty |