Basic Information
| Provider Information | |||||||||
| NPI: | 1679582357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HOSPITAL OF CONVERSE COUNTY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OREGON TRAIL RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1450 | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826331450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073589216 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 EAST BIRCH STREET | ||||||||
| Address2: | |||||||||
| City: | GLENROCK | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074368838 | ||||||||
| FaxNumber: | 3074362476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUGGER | ||||||||
| AuthorizedOfficialFirstName: | CURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3073582122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 07163 | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.