Basic Information
| Provider Information | |||||||||
| NPI: | 1194792457 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RED ROCK FAMILY PRACTICE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N C AVE | ||||||||
| Address2: | |||||||||
| City: | THERMOPOLIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824432410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078645534 | ||||||||
| FaxNumber: | 3078649470 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N C AVE | ||||||||
| Address2: | |||||||||
| City: | THERMOPOLIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824432410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078645534 | ||||||||
| FaxNumber: | 3078649470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | BOMENGEN | ||||||||
| AuthorizedOfficialFirstName: | WADE | ||||||||
| AuthorizedOfficialMiddleName: | TRAVIS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3078645534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 116973400 | 05 | WY | MEDICAID | 116973402 | 05 | WY | MEDICAID | 53D0996144 | 01 | WY | CLIA | OTHER |