Healthcare Provider Details

I. General information

NPI: 1013337880
Provider Name (Legal Business Name): MOUNTAIN REGIONAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ALLEGIANCE CIR
EVANSTON WY
82930-3804
US

IV. Provider business mailing address

PO BOX 6005
EVANSTON WY
82931-6005
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-9371
  • Fax: 307-789-0823
Mailing address:
  • Phone: 307-789-3710
  • Fax: 307-789-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number32521
License Number StateWY

VIII. Authorized Official

Name: RANDY IWEN
Title or Position: CONTROLLER
Credential:
Phone: 307-789-3710