Basic Information
| Provider Information | |||||||||
| NPI: | 1104032416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | URGENT CARE OF JACKSON HOLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8640 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830028640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1415 SOUTH HIGHWAY 89 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | RIVERS | ||||||||
| AuthorizedOfficialFirstName: | FRANKLIN | ||||||||
| AuthorizedOfficialMiddleName: | MUSSER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3077398999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5551A | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QU0200X | 5551A | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1104032416 | 05 | WY | MEDICAID |