Provider Demographics
NPI:1265710628
Name:WYOMING PAIN MEDICINE LLC
Entity type:Organization
Organization Name:WYOMING PAIN MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-213-9713
Mailing Address - Street 1:PO BOX 2508
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-2508
Mailing Address - Country:US
Mailing Address - Phone:307-213-9713
Mailing Address - Fax:180-087-8647
Practice Address - Street 1:707 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3409
Practice Address - Country:US
Practice Address - Phone:307-213-9713
Practice Address - Fax:180-087-8647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8705A261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain