Healthcare Provider Details

I. General information

NPI: 1366108425
Provider Name (Legal Business Name): JCILOA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ERWIN ST
DOUGLAS WY
82633-2914
US

IV. Provider business mailing address

1000 ERWIN ST
DOUGLAS WY
82633-2914
US

V. Phone/Fax

Practice location:
  • Phone: 307-331-3703
  • Fax:
Mailing address:
  • Phone: 307-331-3703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: EDWARD MICHAEL TUCKER
Title or Position: OWNER
Credential:
Phone: 307-331-3703