Healthcare Provider Details

I. General information

NPI: 1629304589
Provider Name (Legal Business Name): BIG HORN BASIN CHILDRENS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SUNSHINE AVE SUITE 101
CODY WY
82414
US

IV. Provider business mailing address

1220 SUNSHINE AVE SUITE 101
CODY WY
82414-4234
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-5545
  • Fax: 307-527-5202
Mailing address:
  • Phone: 307-587-5545
  • Fax: 307-527-5202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4038A
License Number StateWY

VIII. Authorized Official

Name: ROBERT NEIL TREECE
Title or Position: OWNER
Credential: M.D.
Phone: 307-587-5545