Provider Demographics
NPI: | 1689226524 |
---|---|
Name: | WYOMING PHYSICAL THERAPY PC |
Entity Type: | Organization |
Organization Name: | WYOMING PHYSICAL THERAPY PC |
Other - Org Name: | FYZICAL THERAPY AND BALANCE CENTERS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DELEGATED OFFICIAL |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DOUGLAS |
Authorized Official - Middle Name: | K |
Authorized Official - Last Name: | WILSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 307-772-0955 |
Mailing Address - Street 1: | 1217 S GREELEY HWY STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | CHEYENNE |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 82007-3063 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 307-772-0955 |
Mailing Address - Fax: | 307-772-0953 |
Practice Address - Street 1: | 1620 E PERSHING BLVD |
Practice Address - Street 2: | |
Practice Address - City: | CHEYENNE |
Practice Address - State: | WY |
Practice Address - Zip Code: | 82001-3238 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-772-0955 |
Practice Address - Fax: | 307-772-0953 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-07-11 |
Last Update Date: | 2020-02-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |