Healthcare Provider Details

I. General information

NPI: 1528236247
Provider Name (Legal Business Name): IVINSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N 30TH ST
LARAMIE WY
82072-5140
US

IV. Provider business mailing address

255 N 30TH ST
LARAMIE WY
82072-5140
US

V. Phone/Fax

Practice location:
  • Phone: 307-766-9525
  • Fax: 307-766-9510
Mailing address:
  • Phone: 307-742-2142
  • Fax: 307-766-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number7108
License Number StateWY

VIII. Authorized Official

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