Healthcare Provider Details

I. General information

NPI: 1700907029
Provider Name (Legal Business Name): SSC CASPER OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 S POPLAR ST
CASPER WY
82601-6106
US

IV. Provider business mailing address

5300 W SAM HOUSTON PKWY N SUITE 100
HOUSTON TX
77041-5161
US

V. Phone/Fax

Practice location:
  • Phone: 307-237-2561
  • Fax:
Mailing address:
  • Phone: 832-467-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number07187
License Number StateWY

VII. Legacy identifiers

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

# 1
Identifier120859400
Identifier TypeMEDICAID
Identifier StateWY
Identifier Issuer
# 2
Identifier0107451200WY
Identifier TypeOTHER
Identifier StateWY
Identifier IssuerPREVIOUS MEDICAID NUMBER

VIII. Authorized Official

Name: THOMAS P. SIMONS
Title or Position: SENIOR VP OPERATIONS FINANCE
Credential:
Phone: 770-829-5100