Healthcare Provider Details

I. General information

NPI: 1578664066
Provider Name (Legal Business Name): FREMONT COUNTY PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 WYOMING ST
LANDER WY
82520-3919
US

IV. Provider business mailing address

115 WYOMING ST
LANDER WY
82520-3919
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2185
  • Fax: 307-332-7799
Mailing address:
  • Phone: 307-332-2185
  • Fax: 307-332-7799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5774A
License Number StateWY

VIII. Authorized Official

Name: RICHARD E. BARNES
Title or Position: OWNER
Credential: M.D.
Phone: 307-332-2185