Provider Demographics
NPI:1851419832
Name:ADVANTAGE REHAB
Entity Type:Organization
Organization Name:ADVANTAGE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-587-9866
Mailing Address - Street 1:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-1705
Mailing Address - Country:US
Mailing Address - Phone:307-587-9866
Mailing Address - Fax:307-587-9867
Practice Address - Street 1:1819 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3886
Practice Address - Country:US
Practice Address - Phone:307-587-9866
Practice Address - Fax:307-587-9867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY323225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119070900Medicaid
WYW9833Medicare PIN