Provider Demographics
NPI:1629066360
Name:HIGH COUNTRY HOME HEALTH
Entity Type:Organization
Organization Name:HIGH COUNTRY HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-742-3120
Mailing Address - Street 1:3131 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5140
Mailing Address - Country:US
Mailing Address - Phone:307-742-3120
Mailing Address - Fax:307-742-4557
Practice Address - Street 1:3131 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5140
Practice Address - Country:US
Practice Address - Phone:307-742-3120
Practice Address - Fax:307-742-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-157251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY=========OtherTAX ID NUMBER
WY537025Medicare ID - Type UnspecifiedPROVIDER NUMBER
WYIA000029Medicare ID - Type UnspecifiedEDI CUSTOMER NUMBER