Basic Information
Provider Information | |||||||||
NPI: | 1932338530 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RED ROCK FAMILY PRACTICE, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 N C AVE | ||||||||
Address2: |   | ||||||||
City: | THERMOPOLIS | ||||||||
State: | WY | ||||||||
PostalCode: | 824432410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3078645534 | ||||||||
FaxNumber: | 3078649470 | ||||||||
Practice Location | |||||||||
Address1: | 1125 CHARLES AVE | ||||||||
Address2: |   | ||||||||
City: | WORLAND | ||||||||
State: | WY | ||||||||
PostalCode: | 824014021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3073472449 | ||||||||
FaxNumber: | 3078649470 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2009 | ||||||||
LastUpdateDate: | 12/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRIMM | ||||||||
AuthorizedOfficialFirstName: | JENIFER | ||||||||
AuthorizedOfficialMiddleName: | LIN | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING DEPARTMENT | ||||||||
AuthorizedOfficialTelephone: | 3078645534 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.