Healthcare Provider Details

I. General information

NPI: 1245365154
Provider Name (Legal Business Name): BIG HORN FOOT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

777 AVENUE H
POWELL WY
82435-2260
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-9191
  • Fax: 307-954-1291
Mailing address:
  • Phone: 307-754-9191
  • Fax: 307-954-1291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number139
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LAEL J BEACHLER
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 307-754-9191