Provider Demographics
NPI:1720284888
Name:LARAMIE VALLEY MEDICAL, PC
Entity Type:Organization
Organization Name:LARAMIE VALLEY MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLAIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-742-9080
Mailing Address - Street 1:PO BOX 1630
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-1630
Mailing Address - Country:US
Mailing Address - Phone:307-742-9080
Mailing Address - Fax:307-745-8595
Practice Address - Street 1:920 E SHERIDAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3868
Practice Address - Country:US
Practice Address - Phone:307-742-9080
Practice Address - Fax:307-745-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty