Provider Demographics
NPI:1992043327
Name:EDEN VALLEY TELEHEALTH SERVICES
Entity Type:Organization
Organization Name:EDEN VALLEY TELEHEALTH SERVICES
Other - Org Name:BIG SANDY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIODATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-273-3055
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:FARSON
Mailing Address - State:WY
Mailing Address - Zip Code:82932-0359
Mailing Address - Country:US
Mailing Address - Phone:307-273-3055
Mailing Address - Fax:
Practice Address - Street 1:5 HWY 28
Practice Address - Street 2:
Practice Address - City:FARSON
Practice Address - State:WY
Practice Address - Zip Code:82932
Practice Address - Country:US
Practice Address - Phone:307-273-3055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY=========Medicaid
WY=========Medicaid