Healthcare Provider Details

I. General information

NPI: 1164558045
Provider Name (Legal Business Name): MRS. MARY E OPITZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12263 E HENRIE ROADWAY
EVANSVILLE WY
82636-9611
US

IV. Provider business mailing address

12263 E. HENRIE RD
EVANSVILLE WY
82636
US

V. Phone/Fax

Practice location:
  • Phone: 307-234-8019
  • Fax: 307-266-4347
Mailing address:
  • Phone: 307-234-8019
  • Fax: 307-266-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: