Healthcare Provider Details

I. General information

NPI: 1720035249
Provider Name (Legal Business Name): CORAM HEALTHCARE OF WYOMING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2006
Last Update Date: 10/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 STILLWATER AVE SUITE C
CHEYENNE WY
82009-7358
US

IV. Provider business mailing address

1675 BROADWAY SUITE 900
DENVER CO
80202-4675
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-3785
  • Fax: 307-635-7002
Mailing address:
  • Phone: 303-672-8631
  • Fax: 303-298-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License NumberN/A
License Number StateWY

VIII. Authorized Official

Name: VITO PONZIO, JR
Title or Position: SR VP
Credential:
Phone: 303-672-8631