Healthcare Provider Details

I. General information

NPI: 1033628599
Provider Name (Legal Business Name): IVINSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3116 WILLETT DR
LARAMIE WY
82072-5048
US

IV. Provider business mailing address

255 N 30TH ST
LARAMIE WY
82072-5140
US

V. Phone/Fax

Practice location:
  • Phone: 307-742-6319
  • Fax: 307-742-6346
Mailing address:
  • Phone: 307-742-2142
  • Fax: 307-742-2150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES BANDS
Title or Position: CFO
Credential:
Phone: 307-755-4603