Provider Demographics
NPI:1013467851
Name:BIG HORN BASIN CHILDREN'S CLINIC, PC
Entity Type:Organization
Organization Name:BIG HORN BASIN CHILDREN'S CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:TREECE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-587-5545
Mailing Address - Street 1:1220 SUNSHINE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4234
Mailing Address - Country:US
Mailing Address - Phone:307-587-5545
Mailing Address - Fax:
Practice Address - Street 1:1220 SUNSHINE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4234
Practice Address - Country:US
Practice Address - Phone:307-587-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10190A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY140893300Medicaid