Healthcare Provider Details

I. General information

NPI: 1982977732
Provider Name (Legal Business Name): GILLETTE INFUSION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 CRESSETT ST
GILLETTE WY
92716
US

IV. Provider business mailing address

1503 CRESSETT
GILLETTE WY
92716
US

V. Phone/Fax

Practice location:
  • Phone: 307-686-4940
  • Fax:
Mailing address:
  • Phone: 307-686-4940
  • Fax: 307-682-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAOUL JOUBRAN
Title or Position: PRESIDENT
Credential: MD
Phone: 307-686-4940