Provider Demographics
NPI:1922478262
Name:ELEVATE WYOMING LLC
Entity Type:Organization
Organization Name:ELEVATE WYOMING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, FAMILY CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:B
Authorized Official - Last Name:EDGCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:307-620-2008
Mailing Address - Street 1:3 JANICH LN
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-8600
Mailing Address - Country:US
Mailing Address - Phone:307-683-6987
Mailing Address - Fax:
Practice Address - Street 1:3 JANICH LN
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8600
Practice Address - Country:US
Practice Address - Phone:307-763-6987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health