Provider Demographics
NPI:1508999459
Name:WESTSIDE WOMENS CLINIC LLC
Entity Type:Organization
Organization Name:WESTSIDE WOMENS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER BUSINESS MGR
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:CHRISIE
Authorized Official - Last Name:MAMMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-265-5400
Mailing Address - Street 1:1915 OXFORD LANE
Mailing Address - Street 2:STE 101
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604
Mailing Address - Country:US
Mailing Address - Phone:307-265-5400
Mailing Address - Fax:307-265-1818
Practice Address - Street 1:1915 OXFORD LANE
Practice Address - Street 2:STE 101
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604
Practice Address - Country:US
Practice Address - Phone:307-265-5400
Practice Address - Fax:307-265-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
20108Medicare ID - Type Unspecified