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?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty