Provider Demographics
NPI:1679027155
Name:CLEAR CREEK COMPANY LLC
Entity Type:Organization
Organization Name:CLEAR CREEK COMPANY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ADELAIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-337-8247
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-0069
Mailing Address - Country:US
Mailing Address - Phone:307-337-8247
Mailing Address - Fax:
Practice Address - Street 1:63 N BURRITT AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1868
Practice Address - Country:US
Practice Address - Phone:307-337-8247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY136274700Medicaid