Basic Information
Provider Information | |||||||||
NPI: | 1336439041 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEAK WELLNESS CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 W 29TH ST | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820012760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076329362 | ||||||||
FaxNumber: | 3076376852 | ||||||||
Practice Location | |||||||||
Address1: | 510 W 29TH ST | ||||||||
Address2: |   | ||||||||
City: | CHEYENNE | ||||||||
State: | WY | ||||||||
PostalCode: | 820012760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076329362 | ||||||||
FaxNumber: | 3076376852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2011 | ||||||||
LastUpdateDate: | 08/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAISER | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | MATHIAS | ||||||||
AuthorizedOfficialTitleorPosition: | HR DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3076329362 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.