Provider Demographics
NPI:1013337880
Name:MOUNTAIN REGIONAL SERVICES, INC
Entity Type:Organization
Organization Name:MOUNTAIN REGIONAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:IWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-789-3710
Mailing Address - Street 1:PO BOX 6005
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-6005
Mailing Address - Country:US
Mailing Address - Phone:307-789-3710
Mailing Address - Fax:307-789-0823
Practice Address - Street 1:50 ALLEGIANCE CIR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3804
Practice Address - Country:US
Practice Address - Phone:307-778-9371
Practice Address - Fax:307-789-0823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY32521314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility