Healthcare Provider Details

I. General information

NPI: 1801118740
Provider Name (Legal Business Name): WIND RIVER HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2010
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BLACK COAL DRIVE
FORT WASHAKIE WY
82514-0128
US

IV. Provider business mailing address

PO BOX 28 29 BLACK COAL DR
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-0446
  • Fax: 307-332-0131
Mailing address:
  • Phone: 307-332-0446
  • Fax: 307-332-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number19363
License Number StateWY

VIII. Authorized Official

Name: KIMBERLY JO NOT AFRAID
Title or Position: CFO
Credential:
Phone: 307-335-5941