Healthcare Provider Details

I. General information

NPI: 1598942138
Provider Name (Legal Business Name): COAL COUNTRY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 W 4TH ST SUITE 2
GILLETTE WY
82716-3300
US

IV. Provider business mailing address

1206 W 4TH ST SUITE 2
GILLETTE WY
82716-3300
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-3004
  • Fax: 307-682-3558
Mailing address:
  • Phone: 307-682-3004
  • Fax: 307-682-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LORI MCKINSEY
Title or Position: FNP-C
Credential: FNP-C
Phone: 307-682-3004