Healthcare Provider Details

I. General information

NPI: 1962316059
Provider Name (Legal Business Name): SAM ELIOPOULOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 DAKOTA DR
CHEYENNE WY
82001-8543
US

IV. Provider business mailing address

5821 DAKOTA DR
CHEYENNE WY
82001-8543
US

V. Phone/Fax

Practice location:
  • Phone: 307-421-7509
  • Fax:
Mailing address:
  • Phone: 307-421-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: