Healthcare Provider Details

I. General information

NPI: 1366493264
Provider Name (Legal Business Name): BIG COUNTRY REHABILITATION,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 5TH ST
DOUGLAS WY
82633-2434
US

IV. Provider business mailing address

PO BOX 1790
DOUGLAS WY
82633-1790
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-9464
  • Fax:
Mailing address:
  • Phone: 307-358-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LISA MANGUS
Title or Position: CFO
Credential:
Phone: 307-358-9464