Provider Demographics
NPI:1720167562
Name:WYOMING INDEPENDENT LIVING REHABILITATION, INC.
Entity Type:Organization
Organization Name:WYOMING INDEPENDENT LIVING REHABILITATION, INC.
Other - Org Name:WILR
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-266-6956
Mailing Address - Street 1:305 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2405
Mailing Address - Country:US
Mailing Address - Phone:307-266-6956
Mailing Address - Fax:307-266-6957
Practice Address - Street 1:305 W 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2405
Practice Address - Country:US
Practice Address - Phone:307-266-6956
Practice Address - Fax:307-266-6957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY162187251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management