Healthcare Provider Details

I. General information

NPI: 1720167562
Provider Name (Legal Business Name): WYOMING INDEPENDENT LIVING REHABILITATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 1ST ST
CASPER WY
82601-2405
US

IV. Provider business mailing address

305 W 1ST ST
CASPER WY
82601-2405
US

V. Phone/Fax

Practice location:
  • Phone: 307-266-6956
  • Fax: 307-266-6957
Mailing address:
  • Phone: 307-266-6956
  • Fax: 307-266-6957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number162187
License Number StateWY

VIII. Authorized Official

Name: MR. KENNETH L HOFF
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 307-266-6956