Healthcare Provider Details

I. General information

NPI: 1215671185
Provider Name (Legal Business Name): PROSPERA HEALTHCARE WYOMING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W 2ND ST # 2037
CASPER WY
82601-2412
US

IV. Provider business mailing address

312 W 2ND ST # 2037
CASPER WY
82601-2412
US

V. Phone/Fax

Practice location:
  • Phone: 972-900-2488
  • Fax: 972-600-2835
Mailing address:
  • Phone: 972-900-2488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHRIS TILLOTSON
Title or Position: CEO
Credential:
Phone: 972-900-2488