Provider Demographics
NPI:1952372278
Name:SPIRIT MOUNTAIN HOSPICE
Entity Type:Organization
Organization Name:SPIRIT MOUNTAIN HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGALS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-578-2489
Mailing Address - Street 1:707 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3409
Mailing Address - Country:US
Mailing Address - Phone:307-578-2413
Mailing Address - Fax:307-578-2294
Practice Address - Street 1:707 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3409
Practice Address - Country:US
Practice Address - Phone:307-578-2413
Practice Address - Fax:307-578-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY06-181251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106133007Medicaid