Basic Information
| Provider Information | |||||||||
| NPI: | 1699817668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACKSON HOLE MEDICAL CLINIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLERGY & ASTHMA CLINIC OF JACKSON HOLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8640 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830028640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1415 S. HIGHWAY 89 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 83001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077398999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | RIVERS | ||||||||
| AuthorizedOfficialFirstName: | FRANKLIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3077398999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 5551A | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | 1699817668 | 05 | WY | MEDICAID |