Basic Information
| Provider Information | |||||||||
| NPI: | 1245308428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CROOK COUNTY MEDICAL SERVICES DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNDANCE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 517 | ||||||||
| Address2: | 713 OAK STREET | ||||||||
| City: | SUNDANCE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827290517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072833501 | ||||||||
| FaxNumber: | 3072832255 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 OAK STREET | ||||||||
| Address2: | |||||||||
| City: | SUNDANCE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072833501 | ||||||||
| FaxNumber: | 3072832255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LYONS | ||||||||
| AuthorizedOfficialFirstName: | MICKI | ||||||||
| AuthorizedOfficialMiddleName: | DAHNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3072833501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CROOK COUNTY MEDICAL SERVICES DISTRICT | ||||||||
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| AuthorizedOfficialCredential: | DNP | ||||||||
| NPICertificationDate: | 10/16/2020 | ||||||||
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 | 106178006 | 05 | WY | MEDICAID | 106178004 | 05 | WY | MEDICAID |