Provider Demographics
NPI:1982861142
Name:PAMELA MILLS PHYSICAL THERAPIST LLC
Entity Type:Organization
Organization Name:PAMELA MILLS PHYSICAL THERAPIST LLC
Other - Org Name:WILDFLOWER HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:307-265-2461
Mailing Address - Street 1:128 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2739
Mailing Address - Country:US
Mailing Address - Phone:307-265-2461
Mailing Address - Fax:307-265-2492
Practice Address - Street 1:128 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2739
Practice Address - Country:US
Practice Address - Phone:307-265-2461
Practice Address - Fax:307-265-2492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY612261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1210513Medicaid
WY1210513Medicaid
WY20220Medicare PIN