Provider Demographics
NPI:1619413044
Name:POWDER RIVER PHYSICAL MEDICINE & REHABILITATION, LLC
Entity Type:Organization
Organization Name:POWDER RIVER PHYSICAL MEDICINE & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-206-4990
Mailing Address - Street 1:3100 W LAKEWAY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6372
Mailing Address - Country:US
Mailing Address - Phone:307-206-4990
Mailing Address - Fax:307-363-4033
Practice Address - Street 1:3100 W LAKEWAY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6372
Practice Address - Country:US
Practice Address - Phone:307-206-4990
Practice Address - Fax:307-363-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10678A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty