Healthcare Provider Details

I. General information

NPI: 1669606943
Provider Name (Legal Business Name): CANYON RIVER STAFFING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 BLAIR DR APT A
JACKSON WY
83002
US

IV. Provider business mailing address

PO BOX 14622
JACKSON WY
83002-4622
US

V. Phone/Fax

Practice location:
  • Phone: 130-741-3690
  • Fax:
Mailing address:
  • Phone: 130-741-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number18595
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number18595
License Number StateWY

VIII. Authorized Official

Name: MS. MAMIE LOU THURSTON
Title or Position: PRESIDENT AND OWNER
Credential: RN
Phone: 13074136909