Basic Information
Provider Information | |||||||||
NPI: | 1508979535 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN SPORTS MEDICINE AND REHABILITATION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1401 GATEWAY BLVD UNIT 2 | ||||||||
Address2: |   | ||||||||
City: | ROCK SPRINGS | ||||||||
State: | WY | ||||||||
PostalCode: | 829016727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073523626 | ||||||||
FaxNumber: | 3073523628 | ||||||||
Practice Location | |||||||||
Address1: | 1401 GATEWAY BLVD STE 2 | ||||||||
Address2: |   | ||||||||
City: | ROCK SPRINGS | ||||||||
State: | WY | ||||||||
PostalCode: | 829016786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073523626 | ||||||||
FaxNumber: | 3073523628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2006 | ||||||||
LastUpdateDate: | 07/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KNUDSON | ||||||||
AuthorizedOfficialFirstName: | JAELYN | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3073523626 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 118547100 | 05 | WY |   | MEDICAID |