Healthcare Provider Details

I. General information

NPI: 1215971510
Provider Name (Legal Business Name): LANDER VALLEY PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 LINCOLN ST
LANDER WY
82520-2736
US

IV. Provider business mailing address

830 LINCOLN ST
LANDER WY
82520-2736
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-9577
  • Fax: 307-332-3106
Mailing address:
  • Phone: 307-332-9577
  • Fax: 307-332-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number6909A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JESS N JUDY
Title or Position: PRESIDENT
Credential:
Phone: 615-372-8500