MEDICARE: POWELL VALLEY HEALTH CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NR1301X	Rural Acute Care Hospital	10207	WY
2	3416L0300X	Land Ambulance	065	WY
3	282NC0060X	Critical Access Hospital	07084	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	007203	OTHER	WY	BCBS PROVIDER NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497753115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWELL VALLEY HEALTH CARE INC

Provider Business Mailing Address
First Line	:	777 AVENUE H
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435-2260
Country	:	US
Telephone Number	:	307-754-2267
Fax Number	:	307-754-3176

Provider Business Practice Location Address
First Line	:	777 AVENUE H
Second Line	:
City	:	POWELL
State	:	WY
Zip	:	82435
Country	:	US
Telephone Number	:	307-754-1101
Fax Number	:	307-754-3176

Authorized Official
Title or Position	:	CEO
Name	:	MRS. TERRY ODOM
Credential	:
Telephone Number	:	307-754-1107

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	02/07/2022

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1053306662 — DR. DEAN WAYNE BARTHOLOMEW MD
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Practice Location Address:

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1811985112 — BRIAN D. KELLY D.O.
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Directions to “POWELL VALLEY HEALTH CARE INC ” Practice Location

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