Healthcare Provider Details

I. General information

NPI: 1801894522
Provider Name (Legal Business Name): NORTH EAST WYOMING SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 W 3RD ST
GILLETTE WY
82716-3335
US

IV. Provider business mailing address

1307 W 3RD ST
GILLETTE WY
82716-3335
US

V. Phone/Fax

Practice location:
  • Phone: 307-686-8283
  • Fax:
Mailing address:
  • Phone: 307-686-8283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number06015
License Number StateWY

VIII. Authorized Official

Name: MRS. JESSICA HUCKINS
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 307-686-8283