Provider Demographics
NPI:1720035249
Name:CORAM HEALTHCARE OF WYOMING, LLC
Entity Type:Organization
Organization Name:CORAM HEALTHCARE OF WYOMING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:VITO
Authorized Official - Middle Name:
Authorized Official - Last Name:PONZIO, JR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-672-8631
Mailing Address - Street 1:1675 BROADWAY
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-4675
Mailing Address - Country:US
Mailing Address - Phone:303-672-8631
Mailing Address - Fax:303-298-0047
Practice Address - Street 1:1507 STILLWATER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7358
Practice Address - Country:US
Practice Address - Phone:307-635-3785
Practice Address - Fax:307-635-7002
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORAM HEALTHCARE OF WYOMING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-29
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYN/A261QI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy