Healthcare Provider Details

I. General information

NPI: 1770088130
Provider Name (Legal Business Name): S48WY4, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 23RD ST
RAWLINS WY
82301-5127
US

IV. Provider business mailing address

606 23RD ST
RAWLINS WY
82301-5127
US

V. Phone/Fax

Practice location:
  • Phone: 307-342-8820
  • Fax: 307-333-0261
Mailing address:
  • Phone: 307-342-8820
  • Fax: 307-333-0261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. LYNN THOMPSON
Title or Position: PRESIDENT
Credential:
Phone: 307-265-3791