Provider Demographics
NPI:1891994950
Name:S48WY1, LLC
Entity Type:Organization
Organization Name:S48WY1, LLC
Other - Org Name:WYOMING RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-265-3791
Mailing Address - Street 1:231 S. WILSON
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-265-3791
Mailing Address - Fax:307-265-4480
Practice Address - Street 1:231 S. WILSON
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-265-3791
Practice Address - Fax:307-265-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility