Provider Demographics
NPI:1255438651
Name:COUNTY OF CONVERSE
Entity type:Organization
Organization Name:COUNTY OF CONVERSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-358-2536
Mailing Address - Street 1:255 N RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2315
Mailing Address - Country:US
Mailing Address - Phone:307-358-2536
Mailing Address - Fax:307-358-3941
Practice Address - Street 1:255 N RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2315
Practice Address - Country:US
Practice Address - Phone:307-358-2536
Practice Address - Fax:307-358-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107236600Medicaid
WY107236600Medicaid