Provider Demographics
NPI:1659328821
Name:STATE OF WYOMING
Entity Type:Organization
Organization Name:STATE OF WYOMING
Other - Org Name:WYOMING RETIREMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:FAY
Authorized Official - Last Name:TAYLOR-THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-568-2431
Mailing Address - Street 1:890 HIGHWAY 20 S
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-9587
Mailing Address - Country:US
Mailing Address - Phone:307-568-2431
Mailing Address - Fax:307-568-3887
Practice Address - Street 1:890 HIGHWAY 20 S
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410-9587
Practice Address - Country:US
Practice Address - Phone:307-568-2431
Practice Address - Fax:307-568-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-107314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY100176100Medicaid
WY535021Medicare Oscar/Certification