Provider Demographics
NPI:1669796884
Name:FRONTIER WYOMING, LLC
Entity type:Organization
Organization Name:FRONTIER WYOMING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOGUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-693-3840
Mailing Address - Street 1:53 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3346
Mailing Address - Country:US
Mailing Address - Phone:203-693-3840
Mailing Address - Fax:203-693-3841
Practice Address - Street 1:514 E PERSHING AVE
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3618
Practice Address - Country:US
Practice Address - Phone:307-856-4127
Practice Address - Fax:307-856-4129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10306251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1669796884Medicaid
WY1669796884Medicaid