Provider Demographics
NPI:1750475422
Name:MOUNTAIN FALLS CLINIC, P.C.
Entity Type:Organization
Organization Name:MOUNTAIN FALLS CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:S
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-638-7757
Mailing Address - Street 1:2301 HOUSE AVE.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-638-7757
Mailing Address - Fax:307-638-8359
Practice Address - Street 1:2301 HOUSE AVE.
Practice Address - Street 2:SUITE 201
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001
Practice Address - Country:US
Practice Address - Phone:307-638-7757
Practice Address - Fax:307-638-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6272A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9294Medicare ID - Type Unspecified