Basic Information
| Provider Information | |||||||||
| NPI: | 1609220706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLD COYOTE | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PEER SPECIALIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | #24 GREAT PLAINS ROAD | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078650470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Practice Location | |||||||||
| Address1: | #24 GREAT PLAINS ROAD | ||||||||
| Address2: | WHITE BUFFALO RECOVEY CENTER | ||||||||
| City: | ST STEPHENS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078650470 | ||||||||
| FaxNumber: | 3078574383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2016 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.