Healthcare Provider Details

I. General information

NPI: 1255242814
Provider Name (Legal Business Name): IAN CHRESTMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 DELL RANGE BLVD APT 100
CHEYENNE WY
82009-5589
US

IV. Provider business mailing address

3519 HARVEY ST
CHEYENNE WY
82009-4594
US

V. Phone/Fax

Practice location:
  • Phone: 307-256-9605
  • Fax:
Mailing address:
  • Phone: 307-256-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number214041100
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: