MEDICARE: STEPHEN MULLINS

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1508104316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN MULLINS

Provider Business Mailing Address
First Line	:	4989 N 3RD ST
Second Line	:	CATHEDRAL HOME FOR CHILDREN
City	:	LARAMIE
State	:	WY
Zip	:	82073-9548
Country	:	US
Telephone Number	:	307-745-8997
Fax Number	:

Provider Business Practice Location Address
First Line	:	4989 N 3RD ST
Second Line	:	CATHEDRAL HOME FOR CHILDREN
City	:	LARAMIE
State	:	WY
Zip	:	82073-9548
Country	:	US
Telephone Number	:	307-745-8997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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