Healthcare Provider Details

I. General information

NPI: 1033441324
Provider Name (Legal Business Name): LSREF GOLDEN OPS 14 (WY) LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N 22ND ST
LARAMIE WY
82072-5303
US

IV. Provider business mailing address

3015 16TH ST SW STE 100
MINOT ND
58701-6906
US

V. Phone/Fax

Practice location:
  • Phone: 307-755-5811
  • Fax: 307-721-0478
Mailing address:
  • Phone: 701-837-7103
  • Fax: 701-838-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number10226
License Number StateWY

VIII. Authorized Official

Name: TOM WENTZ JR.
Title or Position: EXEC VP/COO
Credential:
Phone: 701-837-7103