Provider Demographics
NPI:1982977732
Name:GILLETTE INFUSION CENTER LLC
Entity Type:Organization
Organization Name:GILLETTE INFUSION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAOUL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUBRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-686-4940
Mailing Address - Street 1:1503 CRESSETT
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:92716
Mailing Address - Country:US
Mailing Address - Phone:307-686-4940
Mailing Address - Fax:307-682-1811
Practice Address - Street 1:1503 CRESSETT ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:92716
Practice Address - Country:US
Practice Address - Phone:307-686-4940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy