Basic Information
| Provider Information | |||||||||
| NPI: | 1275758336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILAR | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VILCHES | ||||||||
| OtherFirstName: | JANE | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1406 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074630463 | ||||||||
| FaxNumber: | 3074632010 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 E CARLSON ST STE 304 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075149999 | ||||||||
| FaxNumber: | 3075146006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2012 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA01048400 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 157091900 | 05 | WY | MEDICAID | PT2012 | 01 | WY | STATE ISSUED PHYSICAL THERAPY LICENSE | OTHER |