Provider Demographics
NPI:1841351954
Name:POWELL VALLEY HEALTH CARE INC
Entity type:Organization
Organization Name:POWELL VALLEY HEALTH CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-754-2267
Mailing Address - Street 1:777 AVENUE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2260
Mailing Address - Country:US
Mailing Address - Phone:307-754-1101
Mailing Address - Fax:307-754-3179
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2260
Practice Address - Country:US
Practice Address - Phone:307-754-1101
Practice Address - Fax:307-754-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07084332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107185804Medicaid
WY007203OtherBCBS PROVIDER #
WY1055000001Medicare NSC