Provider Demographics
NPI:1881834927
Name:SOUTH LINCOLN HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SOUTH LINCOLN HOSPITAL DISTRICT
Other - Org Name:SOUTH LINCOLN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-877-4401
Mailing Address - Street 1:711 ONYX ST
Mailing Address - Street 2:
Mailing Address - City:KEMMERER
Mailing Address - State:WY
Mailing Address - Zip Code:83101-3214
Mailing Address - Country:US
Mailing Address - Phone:307-877-4401
Mailing Address - Fax:307-877-3236
Practice Address - Street 1:711 ONYX ST
Practice Address - Street 2:
Practice Address - City:KEMMERER
Practice Address - State:WY
Practice Address - Zip Code:83101-3214
Practice Address - Country:US
Practice Address - Phone:307-877-4401
Practice Address - Fax:307-877-3236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY09-133275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105993901Medicaid
WY105993901Medicaid