Basic Information
Provider Information | |||||||||
NPI: | 1043453566 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRONTIER WYOMING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRONTIER HOME HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 53 RIVER ST | ||||||||
Address2: | YANKEE PROFESSIONAL BUILDING | ||||||||
City: | MILFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 064603346 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036933840 | ||||||||
FaxNumber: | 2036933841 | ||||||||
Practice Location | |||||||||
Address1: | 4024 LARAMIE ST | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820012064 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076345970 | ||||||||
FaxNumber: | 3076345384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2009 | ||||||||
LastUpdateDate: | 04/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOGUCKI | ||||||||
AuthorizedOfficialFirstName: | MARTHA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2036933840 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | N |   | Agencies | Home Health |   | 251E00000X | 0713064 | WY | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 1043453566 | 05 | WY |   | MEDICAID |