Healthcare Provider Details

I. General information

NPI: 1295959963
Provider Name (Legal Business Name): WIND RIVER RADIOLOGY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 GARFIELD ST
LANDER WY
82520-3121
US

IV. Provider business mailing address

295 GARFIELD ST
LANDER WY
82520-3121
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-6451
  • Fax: 307-335-6467
Mailing address:
  • Phone: 307-332-2357
  • Fax: 307-332-4276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MARY E MAGNUSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 307-332-2357