Basic Information
| Provider Information | |||||||||
| NPI: | 1952497596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LANDER VALLEY MEDICAL CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LANDER REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SEVEN SPRINGS WAY | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159207000 | ||||||||
| FaxNumber: | 6159208913 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 BISHOP RANDALL DR | ||||||||
| Address2: | |||||||||
| City: | LANDER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825203939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076654420 | ||||||||
| FaxNumber: | 3073323548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | BIVACCA | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6159207000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LANDER VALLEY MEDICAL CENTER LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
No ID Information.