Provider Demographics
NPI:1780128967
Name:OLENA MEDICAL WYOMING LLC
Entity type:Organization
Organization Name:OLENA MEDICAL WYOMING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:HARSHVARDHAN
Authorized Official - Middle Name:NANDKISHOR
Authorized Official - Last Name:CHAOBAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-622-4277
Mailing Address - Street 1:222 S GILLETTE AVE
Mailing Address - Street 2:SUITE 705
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3743
Mailing Address - Country:US
Mailing Address - Phone:307-622-4277
Mailing Address - Fax:307-939-7095
Practice Address - Street 1:222 S GILLETTE AVE
Practice Address - Street 2:SUITE 705
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3743
Practice Address - Country:US
Practice Address - Phone:307-622-4277
Practice Address - Fax:307-939-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10449A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty