Provider Demographics
NPI:1699817668
Name:JACKSON HOLE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:JACKSON HOLE MEDICAL CLINIC, LLC
Other - Org Name:ALLERGY & ASTHMA CLINIC OF JACKSON HOLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:307-739-8999
Mailing Address - Street 1:PO BOX 8640
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8640
Mailing Address - Country:US
Mailing Address - Phone:307-739-8999
Mailing Address - Fax:
Practice Address - Street 1:1415 S. HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-739-8999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5551A207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1699817668Medicaid
WY1699817668Medicaid
WYW308126Medicare PIN