Healthcare Provider Details

I. General information

NPI: 1699423616
Provider Name (Legal Business Name): MEADOWS OUTPATIENT CENTER WYOMING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 PIONEER AVE
CHEYENNE WY
82001-4406
US

IV. Provider business mailing address

19820 N 7TH ST STE 205
PHOENIX AZ
85024-1694
US

V. Phone/Fax

Practice location:
  • Phone: 928-684-4083
  • Fax:
Mailing address:
  • Phone: 602-256-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRACY LIVINGSTON
Title or Position: VP OF REVENUE CYCLE
Credential:
Phone: 602-256-3020