Healthcare Provider Details

I. General information

NPI: 1366075707
Provider Name (Legal Business Name): RITE OF PASSAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 E I 80 SERVICE RD
CHEYENNE WY
82009-8781
US

IV. Provider business mailing address

2560 BUSINESS PKWY STE A
MINDEN NV
89423-8961
US

V. Phone/Fax

Practice location:
  • Phone: 307-829-7355
  • Fax:
Mailing address:
  • Phone: 775-392-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RUSTY E. ALEXANDER
Title or Position: BUSINESS MANAGING DIRECTOR
Credential:
Phone: 775-392-2639