Provider Demographics
NPI:1912075102
Name:CROOK COUNTY MEDICAL SERVICES DISTRICT
Entity Type:Organization
Organization Name:CROOK COUNTY MEDICAL SERVICES DISTRICT
Other - Org Name:HULETT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICKI
Authorized Official - Middle Name:DAHNE
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:307-283-3501
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:713 OAK STREET
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-0517
Mailing Address - Country:US
Mailing Address - Phone:307-283-3501
Mailing Address - Fax:307-283-2255
Practice Address - Street 1:122 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HULETT
Practice Address - State:WY
Practice Address - Zip Code:82720
Practice Address - Country:US
Practice Address - Phone:307-467-5281
Practice Address - Fax:307-283-2255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROOK COUNTY MEDICAL SERVICES DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106178007Medicaid
WY106178003Medicaid
WY106178007Medicaid
WY305390Medicare ID - Type UnspecifiedHC PROVIDER NUMBER