Provider Demographics
NPI:1942490891
Name:WIND RIVER HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:WIND RIVER HEALTH SYSTEM, INC
Other - Org Name:RIVERTON COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:307-857-6685
Mailing Address - Street 1:511 N 12TH ST E
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3809
Mailing Address - Country:US
Mailing Address - Phone:307-857-6685
Mailing Address - Fax:307-857-6420
Practice Address - Street 1:511 N 12TH ST E
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3809
Practice Address - Country:US
Practice Address - Phone:307-857-6685
Practice Address - Fax:307-857-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP33534Medicare UPIN