Healthcare Provider Details

I. General information

NPI: 1285396507
Provider Name (Legal Business Name): WYOMING PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E CARLSON ST STE 117
CHEYENNE WY
82009-4335
US

IV. Provider business mailing address

1217 S GREELEY HWY STE A
CHEYENNE WY
82007-3063
US

V. Phone/Fax

Practice location:
  • Phone: 307-772-0955
  • Fax: 307-772-0953
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS K. WILSON
Title or Position: OWNER
Credential:
Phone: 307-772-0955