Healthcare Provider Details

I. General information

NPI: 1598011306
Provider Name (Legal Business Name): ALTA VISTA CENTER FOR INTEGRATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S 2ND ST SUITE B
LARAMIE WY
82070-3611
US

IV. Provider business mailing address

313 S 2ND ST SUITE B
LARAMIE WY
82070-3611
US

V. Phone/Fax

Practice location:
  • Phone: 307-399-3119
  • Fax: 866-827-3930
Mailing address:
  • Phone: 307-399-3119
  • Fax: 866-827-3930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7766A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number7766A
License Number StateWY

VIII. Authorized Official

Name: DR. WILLIAM S. FITTERMAN
Title or Position: CEO/MEDICAL DIRECTOR
Credential: D.O.
Phone: 307-399-3119