Basic Information
| Provider Information | |||||||||
| NPI: | 1396842308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LANDER VALLEY MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | LANDER REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 BISHOP RANDALL DR | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073324420 | ||||||||
| FaxNumber: | 3073323548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | BIVACCA | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 06149 | WY | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 00371001 | 01 | WY | BCBS PROFESSIONAL FEES | OTHER | 041434 | 01 | WY | BCBS | OTHER | 115864303 | 05 | WY | MEDICAID | 115864300 | 05 | WY | MEDICAID | 115864305 | 05 | WY | MEDICAID | 115864304 | 05 | WY | MEDICAID |