Basic Information
Provider Information | |||||||||
NPI: | 1801894522 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH EAST WYOMING SURGERY CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1307 W 3RD ST | ||||||||
Address2: |   | ||||||||
City: | GILLETTE | ||||||||
State: | WY | ||||||||
PostalCode: | 827163335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076868283 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1307 W 3RD ST | ||||||||
Address2: |   | ||||||||
City: | GILLETTE | ||||||||
State: | WY | ||||||||
PostalCode: | 827163335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076868283 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 05/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUCKINS | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3076868283 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | R.N. | ||||||||
NPICertificationDate: | 05/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 06015 | WY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.